Resource development takes place through the transformation of social institutions. The moral dimension is of crucial importance in the evolution of associated management regimes. More than just a code of ethics, moralities are predicated on what is understood to be ‘the good’. Recognition of the good requires a rhetoric beyond those of power and interest. This paper proposes a rhetoric of love. Within this conception of morality, the management of human relationships becomes understood as an unfolding cycle of choice among (...) tragic choices and management of the non‐human environment is accomplished through the realisation of the gift relationship. (shrink)

How much by way of economic reward is due to health care providers?Although this problem usually presents itself as a practical matter of policy, it has buried within it a number of philosophical issues, for it can be regarded as a question in the theory of economic justice. The formal principle of justice is that we should render persons what is due to them. But on what consideration in the case of health care providers can we make an assessment of (...) what is due?The answer we give to this question has significant implications for the ethical appraisal of the allocation of resources in the health care system. Some of the most difficult issues of ethical appraisal emerge when we consider the problems of allocating potentially life-saving resources between different groups of patients. Many of the most significant current issues in medical ethics—the role of QALYs, the meaning of equality and the economic evaluation of life—find their point of reference in the ‘tragic choices’ that are created when there are insufficient resources to meet apparently legitimate medical need. Yet, as Robert Evans has pointed out, it is a simple matter of accounting identity that health care expenditures must equal health providers' incomes. So, in asking how we limit or allocate costly health care resources, we are implicitly offering an answer to the question of how much we should pay providers. I hope by seeking an answer explicitly to that question to throw light on the problems that are raised when considering ethically the allocation of health care resources. (shrink)

The Ministry of Transport is planning for the construction of new roads in its territory. Many projects are being considered, and the Ministry needs to identify the worthwhile projects for which the benefits exceed the costs. Among costs and benefits are the expense of constructing the road, the time saved by motorists using the new road rather than some other road, the time saved through the reduction of congestion on other roads, and the expected increase or decrease in the number (...) of deaths due to traffic accidents. I am concerned in this paper with the last item on the list. It is, of course, difficult to estimate fatalities accurately, but this difficulty is neither unique nor central to our problem. The problem is how best to place a monetary value on fatalities, so that the expected number of fatalities can be compared with other costs and benefits in deciding whether to build a road. However chosen, the monetary value of fatalities for use in this context is what the economist means by “the value of life.” The term is almost a joke, a bit of gallows humor to exorcise the ghoulishness that inevitably clings to analysis of life and death in monetary terms. (shrink)

Courts are increasingly obliged to adjudicate upon challenges to allocative decisions in healthcare, but their involvement continues to be regarded with unease, imperilling the legitimacy of the judicial role in this context. A central reason for this is that judges are perceived to lack sufficient expertise to determine allocative questions. This article critically appraises the claim of lack of judicial expertise through an examination of the various components of a limit-setting decision. It is argued that the inexpertise argument is weak (...) when compared with other rationales for judicial restraint, such as the procedural unsuitability and lack of constitutional competence of courts. (shrink)

We can enjoy and suffer many kinds of human goods and evils. The goods include not only experiences and enjoyments but also the having and exercise of various talents and abilities, the receipt of recognitions and rewards, successes, employments, opportunities. The evils include not only pains and frustrations but also defects such as ugliness, disabilities such as paralysis or retardation, lack of standard opportunities such as unemployment, financial loss, failure, disgrace. It is tempting to say that wherever a person has (...) a good he has an advantage and when he suffers an evil he is, in that respect, disadvantaged. However this usage can make it look as if all human goods and evils are subject matter for distributive justice. In fact that is not the conventional view. (shrink)

“One man’s ceiling is another man’s floor”Paul SimonThe words of Paul Simon capture the essence of what the courts are called upon to deal with when adjudicating matters of health. Wealthier and healthier neighbors living in the upstairs apartment are, all things being equal, not overly interested in raising the floor of their apartment in order to create more space for those in the apartment below. The floor is tangible, measurable and movable, and thus a subject where science can contribute (...) much. However, where to locate the floor is a matter of values and thus largely in the realm of politics.Resorting to the courts in matters of public policy can be seen as the residual of the inability of the remaining two branches of government, the legislature and the executive, to succeed in allocating resources and regulating the system. When the combination of science and politics falters, enter the judiciary. (shrink)

“One man’s ceiling is another man’s floor”Paul SimonThe words of Paul Simon capture the essence of what the courts are called upon to deal with when adjudicating matters of health. Wealthier and healthier neighbors living in the upstairs apartment are, all things being equal, not overly interested in raising the floor of their apartment in order to create more space for those in the apartment below. The floor is tangible, measurable and movable, and thus a subject where science can contribute (...) much. However, where to locate the floor is a matter of values and thus largely in the realm of politics.Resorting to the courts in matters of public policy can be seen as the residual of the inability of the remaining two branches of government, the legislature and the executive, to succeed in allocating resources and regulating the system. When the combination of science and politics falters, enter the judiciary. (shrink)

How valuable is the market mechanism for practical morality? What is its moral standing? We can scarcely doubt that as individuals we do value tremendously the opportunity of using markets. Indeed, without access to markets most of us would perish, since we don't typically produce the things that we need to survive. If we could somehow survive without using markets at all, our quality of life would be rather abysmal. It is natural to feel that an institution that is so (...) crucial to our well-being must be valuable. And since moral evaluation can hardly be indifferent to our interests and their fulfillment, it might appear that there is nothing much to discuss here. The market's moral standing “has to be” high. (shrink)

American society tends to medicalize or criminalize social problems. Criminal justice reformers have made arguments for a positive role in the relief of poverty that are similar to those aired in healthcare today. The consequences of criminalizing poverty caution against its continued medicalization.

The purpose of this article is to re-visit how rationing is defined for a health-care context, Two reasons justify returning to this topic. First, the variability as to how rationing has been defined in the legal, medical, and philosophical literature justifies a careful examination to identify its critical features. Second, I believe that if the definitions typically employed in the literature, several of which are discussed below, are compared to those that would be offered by the American public, ethically weighty (...) dissimilarities would be apparent. Disparate characterizations are worrisome because serious “disconnections” between policymakers’ understandings, rhetoric, and priorities and those of the general public are more likely. (shrink)

The purpose of this article is to re-visit how rationing is defined for a health-care context, Two reasons justify returning to this topic. First, the variability as to how rationing has been defined in the legal, medical, and philosophical literature justifies a careful examination to identify its critical features. Second, I believe that if the definitions typically employed in the literature, several of which are discussed below, are compared to those that would be offered by the American public, ethically weighty (...) dissimilarities would be apparent. Disparate characterizations are worrisome because serious “disconnections” between policymakers’ understandings, rhetoric, and priorities and those of the general public are more likely. (shrink)

Periodic and unexpected shortages of drugs, biologics, and even medical devices have become commonplace in the United States. When shortages occur, hospitals and clinics need to decide how to ration their available stock. When such situations arise, institutions can choose from several different allocation schemes, such as first-come, first-served, a lottery, or a more rational and calculated approach. While the first two approaches sound reasonable at first glance, there are a number of problems associated with them, including the inability to (...) make fine, individual patient-centered decisions. They also do not discriminate between what kinds of patients and what types of uses may be more deserving or reasonable than others. In this article I outline an ethically acceptable procedure for rationing drugs during a shortage in which demand outstrips supply. (shrink)

The current outbreak of Ebola virus infection in West Africa continues to spread. Several patients have now been treated in the United States and preparations are being made for more. Because of the strict isolation required for their care, questions have been raised about what diagnostic and therapeutic interventions should be available. I discuss the ethical challenges associated with caring for patients in strict isolation and personnel wearing bulky protective gear with reduced dexterity and flexibility, the limitations this may place (...) on available treatments and the permissibility of consequent departures from the standards of care. Restricting access to some interventions such as surgery requiring an operating room, advanced imaging, etc. is reasonable due to concern for protecting other patients, visitors and staff. Cardiopulmonary resuscitation is a special case and the implications for withholding this intervention in situations where it may be desired is discussed, especially with respect to those patients who have suspected, but not proven, infection. These same restrictions are also considered under conditions where there are scarce resources and thus limited numbers of patients may receive care. While it is to be hoped that there is only limited and sporadic infection with Ebola virus in the US, careful thought must be given to the care of these patients under the unusual circumstances demanded by their isolation. I argue that an altered standard of care is reasonable and ethically acceptable under certain conditions. (shrink)

The potential for genetic engineering of enhancements to complex human traits has been the subject of vigorous debate for a number of years. Most of the discussion has centered on the possible moral consequences of pursuing enhancements, especially those that might affect complex behaviours and components of personality. Little has been written on the actual process of implementing this technology. This paper presents a ‘thought experiment’ about the likely form of final preclinical testing for a technology to enhance intelligence as (...) a prototypical multiplex trait. The significance and the potential dangers of implementing enhancements in humans, especially to highly valued traits such as intelligence, would mandate a thorough programme of testing in animals, including non-human primates such as chimpanzees. The implications this would have for researchers, society and, most importantly, the animals themselves are discussed, and the paper concludes with a suggestion for a morally justifiable approach to resolve the tragic question of what to do with research animals who have a cognitive capacity that is close to that of humans. (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)

The current Ebola virus epidemic in Western Africa appears to be spiraling out of control. The worst-case projections suggested that the unchecked spread could result in almost 1.4 million cases by the end of January 2015 with a case fatality rate of at least 50%. The United States and European nations have begun to respond in earnest with promises of supplies, isolation beds, and trained health care personnel in an effort to contain the epidemic and care for the sick. However, (...) there is neither a vaccine nor specific treatment for Ebola infection, and therapy is ideally centered on supportive care. I have previously argued that the provision of palliative care is obligatory during an overwhelming health catastrophe, notably pandemic influenza. Since affected Ebola patients have best outcomes with technologically advanced intensive care—resources in scarce supply in the area—I suggest that the only acceptable approach to large numbers of very sick, dying, and suffering Ebola patients who overwhelm the reso.. (shrink)

Resource development takes place through the transformation of social institutions. The moral dimension is of crucial importance in the evolution of associated management regimes. More than just a code of ethics, moralities are predicated on what is understood to be 'the good'. Recognition of the good requires a rhetoric beyond those of power and interest. This paper proposes a rhetoric of love. Within this conception of morality, the management of human relationships becomes understood as an unfolding cycle of choice among (...) tragic choices and management of the non-human environment is accomplished through the realisation of the gift relationship. (shrink)

COVID-19 is reducing the ability to perform surgical procedures worldwide, giving rise to a multitude of ethical, practical and medical dilemmas. Adapting to crisis conditions requires a rethink of traditional best practices in surgical management, delving into an area of unknown risk profiles. Key challenging areas include cancelling elective operations, modifying procedures to adapt local services and updating the consenting process. We aim to provide an ethical rationale to support change in practice and guide future decision-making. Using the four principles (...) approach as a structure, Medline was searched for existing ethical frameworks aimed at resolving conflicting moral duties. Where insufficient data were available, best guidance was sought from educational institutions: National Health Service England and The Royal College of Surgeons. Multiple papers presenting high-quality, reasoned, ethical theory and practice guidance were collected. Using this as a basis to assess current practice, multiple requirements were generated to ensure preservation of ethical integrity when making management decisions. Careful consideration of ethical principles must guide production of local guidance ensuring consistent patient selection thus preserving equality as well as quality of clinical services. A critical issue is balancing the benefit of surgery against the unknown risk of developing COVID-19 and its associated complications. As such, the need for surgery must be sufficiently pressing to proceed with conventional or non-conventional operative management; otherwise, delaying intervention is justified. For delayed operations, it is our duty to quantify the long-term impact on patients’ outcome within the constraints of pandemic management and its long-term outlook. (shrink)

Health-care goods are goods with peculiar properties, and where they are scarce, societies face potentially explosive distributional conflicts. Animated public and academic debates on the necessity and possible justice of limit-setting in health care have taken place in the last decades and have recently taken a turn toward procedural rather than substantial criteria for justice. This article argues that the most influential account of procedural justice in health-care rationing, presented by Daniels and Sabin, is indeterminate where concrete properties of rationing (...) institutions are concerned. Such properties inscribe substantial norms into institutions. These norms can derive validity only from democratic majority decisions, which must be seen as an instance of pure procedural justice. We therefore have to move the discussion to a meta-level and ask how concrete properties of institutions are being chosen. I suggest four criteria for sufficiently democratic institutional design choice and conclude that as institutional properties are likely to have effects on the resulting distribution of health care, design choices should be empirically informed and taken both democratically and deliberately. (shrink)

Was society’s response adequate in the cases of Mrs Pretty and Ms B?On the 11th of May, less than two weeks after losing her final legal appeal, Mrs Diane Pretty died, under sedation and in the care of a hospice. It was not the end she had pursued through the English High Court, the Court of Appeal, the House of Lords, and the European Court of Human Rights. Paralysed by motor neurone disease and unable to take her own life, Mrs (...) Pretty wanted her husband to be allowed to help her to die when they decided the time had come. But in England, assisting suicide is a crime, although suicide itself no longer is, and the English courts refused Mrs Pretty’s request to grant her husband legal immunity. In turning to the European Court of Human Rights, Mrs Pretty argued that the English courts’ refusal had violated the European Convention on Human Rights.The European court, however, judged that there had been no violation. The right to life could not be construed as conferring a “right to die”, and consequently the state could not be required to “sanction actions intended to terminate life” in order to protect Mrs Pretty from the “inhuman or degrading treatment” to which she claimed the law on assisted suicide subjected her. The right to respect for private life , moreover, had to be exercised “in accordance with the law” of the state concerned. “States were entitled to regulate through the operation of the general criminal law activities which were detrimental to the life and safety of other individuals”; and such activities were what the English law against assisting suicide was designed to prevent. Exceptions to this law could not be allowed without undermining the …. (shrink)

The current ethical-legal consensus — prohibiting assisted suicide and euthanasia, but (1) allowing patients to forgo all life-saving treatment, and (2) permitting pain relief that increases the risk of death — is a means of having it both ways. This is how we often make “tragic choices.”.

I sometimes wonder whether some proponents of physician-assisted suicide or physician-assisted death think they own the copyright to such catchy phrases as “death with dignity” and “a good death” so that if you are against PAS or PAD, thenyou must be againsta dignified death or a good death. If one removes the quotation marks around phrases like “aid-in-dying” or “compassionate care for the dying,” I am not opposed to such end-of-life care either. Indeed, how couldanybodybe against this type of care?I (...) do not want to abandon dying patients anymore than Dr. Timothy Quill does. Although, unfortunately, it will not always be easy to achieve the desired result, I agree with him that it ought to be a goal of medicine “to help people die well, to help them receive a good death” — or at least “the best possible” death under the circumstances. I part company with Professor Quill, however, when he urges us to change the law in the majority of our states so that in some circumstances patients may achieve a “good death” or a “dignified” one by means of lethal drugs. (shrink)

The prospect of rescuing a person in immediate peril seems at first glance to be an unqualified good. Take, for example, the events of April 15, 2013, at the 117th Boston Marathon. Two consecutive...

During the last two decades a broad and intensive discussion has taken place in the field of medical ethics. Especially in the English-speaking countries, “Biomedical Ethics” have developed as a part of secular, philosophical moral theory. Two ethical problems in organ transplantation – living organ donation and organ allocation – illustrate that this transition reflects both the complex ethical questions raised by rapid changes in the biological sciences and in health care, and the fact that traditional Hippocratic ethics have proven (...) to be inadequate in several respects. (shrink)

The American Journal of Bioethics, Volume 12, Issue 1, Page 20-22, January 2012.

Extreme intentional and deliberate violence against innocent people, including acts of terror and school shootings, poses various ethical challenges, some related to the practice of medicine. We discuss a dilemma relating to deliberate violence, in this case the aftermath of a terror attack, in which there are multiple injured individuals, including the terror perpetrator. Normally, the priority of medical treatment is determined based on need. However, in the case of a terror attack, there is reason to question this. Should the (...) perpetrator of extreme violence receive medical treatment on the scene before the victims if he or she is designated as the most seriously injured? Or rather, should victims receive medical care priority if they are also in some life-threatening danger, although not at the same level of severity as the perpetrator? We present two opposing approaches: the conventional ‘no-exceptions’ approach, which gives priority to the terrorist, and the justice-oriented ‘victim first’ approach, which gives priority to the victims. Invoking concepts of retributive justice, distributive justice and corrective justice, this latter approach suggests that ‘value-neutrality’ can lead to injustice. Perpetrators of terror-like violence should be treated as an act of humanism and good ethical medical practice. However, in clear and obvious terror-like situations, to treat the perpetrators of violence before their victims may be unjust. Thus, in some specific situations, the ‘victim first’ approach may be considered a legitimate alternative triage policy. (shrink)

The purpose of this article is to offer guidelines to deal with hard choices, specifically in situations where some compromise among opposing values is inescapable. The guidelines are intended to help ethicists and practitioners to delineate different alternatives and to dismiss some of them as morally unacceptable. This article explores the view that compromises arise from negotiations but from ethical predicaments as well. For this reason, I distinguish between strategic and moral compromises. Both managers and employees are individual moral agents (...) who have to confront the possibility of unpalatable and even disgusting compromises, so that they are forced to put their integrity into risk in certain compromise situations. However, I shall argue for the possibility of palatable moral compromises. The guidelines to cope with those situations and to identify the unpalatable compromises are based on J. S. Mill's moral philosophy. Mill suggested that half-measures passed in Parliament must have certain key elements to be morally acceptable. I make use of this doctrine to put forward compromise guidelines in the form of a set of hallmarks, internal and external elements of palatable compromises. Two minicases are used to test the guidelines and to emphasize the importance of compromises for ethical decision making and commitment to company. (shrink)

The papers in this issue of the Journal of Medical Ethics address various aspects of five familiar areas of bioethical enquiry: transplantation, genetics, euthanasia, research ethics and professional practice. That these areas, despite all that has been written about them, continue to provoke productive scholarly attention, testifies not only to their existential relevance but also to their moral complexity. Countless human lives will be affected, for better or worse, by how moral decisions in these areas are taken, communicated and implemented. (...) It is of the greatest importance therefore that the ethical thinking informing not only such decisions but also the practices of which they are part, should be both principled and appropriately contextualised. To that end, familiar moral attitudes, assumptions and arguments require repeatedly to be challenged from a variety of perspectives, not ultimately to discover any definitive unravelling of moral complexity, but rather to inform more thoughtful and nuanced responses to the diverse manifestations of that complexity. As Calbresi and Bobbitt have observed: ‘a moral society must depend on moral conflict as the basis for determining morality’. 1 The papers in this issue, written from a variety of cultural, as well as ethical, legal and clinical perspectives, each can assist in that process.For over half a century the subject of organ transplantation has attracted ethical debate. One such ongoing debate, provoked by the severe scarcity of organs for transplantation and a concern to increase their supply, has been about why willing live donors should continue to be prohibited from offering their own organs for sale. Against allowing this, it has often been argued that prohibition protects people in poverty from being driven to, and then harmed by, this desperate last resort. …. (shrink)

In practical reasoning, reasonableness ‐ as opposed to rationality ‐ is an important concept. This paper explores the notion of reasonableness as applied exclusively to legal decisions. Conflicting values or legal requirements can make rationally deduced solutions unattainable, and may call for criteria of reasonableness, Conflicting values must be weighed, and weighed against each other, in search of a point of equilibrium between them. Legal cases are more or less difficult to solve, depending on the difficulty of finding a unique (...) optimal equilibrium. The relevance of factual and ideal consensus for the determination of a reasonable legal decision is underlined. Finally, a definition of “reasonable legal decision” is proposed. (shrink)

The article focuses on the definition of constitutional conflicts as moral dilemmas. It discusses the conception of tragic conflicts by which “loss” is a distinctive feature that identifies both moral and constitutional dilemmas. It also asserts the peculiarity of constitutional conflicts vis-à-vis moral dilemmas, as well as the possibility of legal solutions to constitutional conflicts.

El artículo defiende que los compromisos son tanto un tipo de acuerdo como un tipo de decisión. Los principales objetivos son: 1) identificar la estructura formal de las situaciones de compromiso en las que alguna decisión de compromiso es inevitable, incluyendo CDs que ponen en riesgo la integridad del decisor; 2) mediante las nociones de juicio básico y compulsivo propuestas por Amartya Sen, establecer cuándo una CD en una situación de compromiso podría estar moralmente justificada. Se concluye que las CDs (...) justificadas implican una contrición moral que ayuda a salvar la distancia entre deontología y consecuencialismo. (shrink)