Bioethics can be considered as a topic, an academic discipline, a field of study, an enterprise in persuasion. The historical specificity of the forms bioethics takes is significant, and raises questions about some of these approaches. Bioethics can also be considered as a governance practice, with distinctive institutions and structures. The forms this practice takes are also to a degree country specific, as the paper illustrates by drawing on the author’s UK experience. However, the UNESCO Universal Declaration on Bioethics can (...) provide a starting point for comparisons provided that this does not exclude sensitivity to the socio-political context. Bioethics governance practices are explained by various legitimating narratives. These include response to scandal, the need to restrain irresponsible science, the accommodation of pluralist views, and the resistance to the relativist idea that all opinions count equally in bioethics. Each approach raises interesting questions and shows that bioethics should be studied as a governance practice as a complement to other approaches. (shrink)

Die Behandlung von einwilligungsunfähigen psychisch kranken Menschen mit neuen Therapiemethoden ist insbesondere im Kontext des „individuellen Heilversuchs“, der als Anwendung wenig erprobter Therapieansätze im Rahmen von „ultima ratio“-Entscheidungen charakterisiert ist, mit ethischen Abwägungsproblemen verbunden. Diese bestehen aufgrund von Einschränkungen in der Handlungs- und Entscheidungsautonomie der betroffenen Patienten und, aufgrund eigen- oder fremdgefährdender Symptome der psychischen Krankheit selbst, insbesondere in der praktischen Umsetzung ethisch akzeptierter Modelle stellvertretender Entscheidung sowie in der Wahl des Bezugspunkts der Nutzen-Risiko-Analyse des intendierten Therapieverfahrens. Der Artikel untersucht (...) den ethischen Konflikt zwischen gerechtfertigter Hilfeleistung und Instrumentalisierungsrisiko psychisch kranker Menschen zu Fremdzwecken am historischen Beispiel der „Rindenexcisionen“ des Psychiaters Gottlieb Burckhardt (1836–1907). Als Lösungsmöglichkeit dieses ethischen Konflikts wird das „Konzept des kontrollierten individuellen Heilversuchs“ diskutiert. (shrink)

The principles underpinning Islam's ethical framework applied to routine clinical scenarios remain insufficiently understood by many clinicians, thereby unfortunately permitting the delivery of culturally insensitive healthcare. This paper summarises the foundations of the Islamic ethical theory, elucidating the principles and methodology employed by the Muslim jurist in deriving rulings in the field of medical ethics. The four-principles approach, as espoused by Beauchamp and Childress, is also interpreted through the prism of Islamic ethical theory. Each of the four principles is investigated (...) in turn, looking in particular at the extent to which each is rooted in the Islamic paradigm. This will provide an important insight into Islamic medical ethics, enabling the clinician to have a better informed discussion with the Muslim patient. It will also allow for a higher degree of concordance in consultations and consequently optimise culturally sensitive healthcare delivery. (shrink)

Nancy Jecker (2013) mounts a sustained and formidable critique of Norman Daniels's prudential lifespan account (PLA) as a reliable basis for justice between age groups in the responsible allocation...

Ageing is often deemed bad for people and something that ought to be eliminated. An important aspect of this normative aspect of ageing is whether ageing, i.e., senescence, is a disease. In this essay, I defend a theory of disease that concludes that ageing is not a disease, based on an account of natural function. I also criticize other arguments that lead to the same conclusion. It is important to be clear about valid reasons in this debate, since the failure (...) of bad analyses is exploited by proponents of the view that ageing is indeed a disease. Finally, I argue that there could be other reasons for attempting to eradicate senescence, which have to do with an evaluative assessment of ageing in relation to the good life. I touch on some reasons why ageing might be good for people and conclude that we cannot justify generalized statements in this regard. (shrink)

This paper suggests that medical education be revised to assist in diffusing potential ethical dilemmas that arise during health care provision. A revised medical education would emphasize the role of the humanities in the training of physicians, especially in light of recent critiques of the canonical scientific model in general, and more specifically in the use of that model for medical training and practice.

Elselijn Kingma maintains that Christopher Boorse and other naturalists in the philosophy of medicine cannot deliver the value-free account of disease that they promise. Even if disease is understood as dysfunction and that notion can be applied in a value-free manner, values still manifest themselves in the justification for picking one particular operationalization of dysfunction over a number of competing alternatives. Disease determinations depend upon comparisons within a reference class vis-à-vis reaching organism goals. Boorse considers reference classes for a species (...) to consist in the properties of age and sex and organism goals to comprise survival and reproduction. Kingma suggests that naturalists are influenced by value judgments and may rely upon implicit assumptions about disease in their choice of reference classes and goals to determine which conditions are diseased. I argue that she is wrong to claim that these choices cannot be defended without arguing in a circular manner or making certain arbitrary or value-driven judgments. (shrink)

In this paper I: (1) Describe something of the present situation in the United States and briefly contrast this with the state of affairs in other nations of the industrialised world. I emphasise health care but also allude to other social conditions: health care is merely one institution of a society and, just as do its other institutions, the system of health care reflects the basic world-view of that society. (2) Sketch the world-view and the philosophy which underwrites the use (...) of a market system in distributing what are acknowledged to be critically important social goods like health care and higher education. I show that a well-functioning market can indeed be useful when it comes to distributing some, but not when distributing other goods. (3) Suggest that when competition and the market are used to ‘regulate’ health care, technology—instead of being used to benefit patients—is apt to be used primarily to maximise individual profit: it becomes a weapon between what is often painted as ‘warfare’ among health care providers and institutions. I argue that this state of affairs is based on an undue emphasis upon the demands of individual freedom to the detriment of the community. Finally (4) I suggest an alternative approach to balancing individual with communal interests, an approach which is neither based on a predominance of one with neglect of the other, nor on a dialectic balance between them, but rather upon an approach which sees both individual and communal interests as modifying forces in a complex homeostatic balance. Individual success, in any civilised sense of the term, is possible only in a viable and well-functioning community, and a well-functioning community is not possible without individual success: the two are inevitably interdependent and linked. (shrink)

Nurse philosopher Sally Gadow (1999) has proposed the relational narrative between patient and nurse as a ‘postmodern turn’ for nursing ethics. She has conceptualized this moral approach as the construction by patient and nurse of a coauthored narrative describing the good they are seeking, as well as the means to achieve this good. The purpose of this article is to provide an elaboration of Gadow's seminal conceptualization of relational narrative based on her writings and those of other philosophers. The article (...) will further develop relational narrative's foundations in relationship and narrative and will explore engagement as a dimension essential to its creation and growth. The elaboration first builds on the notion of relationship as foundational to this postmodern moral perspective. Narrative then is advanced as being at the heart of the patient–nurse relationship and their relational narrative, based on an exploration of narrative's role in the moral realm as an epistemology for patient and nurse. Finally, the dialogic and embodied engagement expressed by a relational narrative is developed as a critical element of the ethic. (shrink)

This paper argues that we have wrongly and not for the patient’s benefit made a form of stark autonomy our highest value which allows physicians to slip out from under their basic duty which has always been to pursue a particular patient’s good. In general – I shall argue – it is the patient’s right to select his or her own goals and the physician’s duty to inform the patient of the feasibility of that goal and of the means needed (...) to attain it. If the goal is not one that is possible, the patient, with the physician and family, must select a feasible goal and then discuss the costs/benefits of various approaches. The physician should take a leading role in helping the patient select the goal. I argue that to simply present a laundry list of means and insist that patients choose for themselves is not only abandoning patients to their autonomy but is, in fact, a crass form of violating the patient’s autonomy. Freely choosing not to choose is a choice a patient with decisional capacity is entitled to make and one that needs to be respected. (shrink)

Several commentators have tried to ground legal prohibitions of kidney sales in some form of Kant’s moral arguments against such sales. This paper reconsiders this approach to justifying laws and policies in light of Kant’s approach to law in his political philosophy. The author argues that Kant’s political philosophy requires that kidney sales be legally permitted, although contracts for such sales must remain unenforceable. The author further argues that Kant’s approach to laws, such as those governing kidney distribution, was formed (...) in part by considering and rejecting an assumption frequently employed in the bioethics literature, namely, that legal duties can be grounded directly in moral duties. The author explains some of Kant’s reasons for rejecting this assumption and concludes that arguments pertaining to the legality of kidney sales developed on the basis of Kant’s moral philosophy should no longer be considered tenable. (shrink)

Medicalization appears to be an issue that is both ubiquitous and unquestionably problematic as it seems to signal at once a social and existential threat. This perception of medicalization, however, is nothing new. Since the first main writings in the 1960s and 1970s, it has consistently been used to describe inappropriate or abusive instances of medical authority. Yet, while this standard approach claims that medicalization is a growing problem, it assumes that there is simply one “medical model” and that the (...) expanding realm of “the medical” can be more or less clearly delineated. Moreover, while intended to establish the reality of this growing threat, this research often requires making arbitrary or unjustified distinctions between different practices. To better clarify the concept of medicalization, I will focus more on capturing the variety of medical practices than on the sociological aspects of medical discourse. In doing so, I will explore the distinction between medicalization and pathologization, a distinction that is often overlooked and that brings with it many conceptual and practical implications. After defining these terms, I will use some examples to show that while pathologizing is closely tied to medicalizing, both can occur independently. I will then further develop this distinction in terms of the different individual and social effects of these practices. (shrink)

This paper addresses three factors that have contributed to shifts in decision making in health care. First, the notion of patient autonomy, which has changed due to the rise of patient-centred approaches in contemporary health care and the re-conceptualization of the physician-patient relationship. Second, the understanding of patient autonomy has broadened to better engage patient participation. Third, the need to develop cross-cultural health care ethics. Our paper shows that the shift in the West from the individual to the relational self (...) indicates an important change in the understanding of autonomy through the lens of culture. Practices that recognize the notion of the relational self allow for a more balanced view of autonomy and a richer conception of moral agency. (shrink)

In this article we critically examine the principle of equivalence of care in prison medicine. First, we provide an overview of how the principle of equivalence is utilized in various national and international guidelines on health care provision to prisoners. Second, we outline some of the problems associated with its applications, and argue that the principle of equivalence should go beyond equivalence to access and include equivalence of outcomes. However, because of the particular context of the prison environment, third, we (...) contend that the concept of “health” in equivalence of health outcomes needs conceptual clarity; otherwise, it fails to provide a threshold for healthy states among inmates. We accomplish this by examining common understandings of the concepts of health and disease. We conclude our article by showing why the conceptualization of diseases as clinical problems provides a helpful approach in the delivery of health care in prison. (shrink)

The doctor's use of deception in appropriate circumstances has commonly been considered a necessity of the medical art. Resistance to full and frank communication is typical of many traditionally Catholic countries, and particularly of Italy, a western country where Catholicism remains particularly influential. The Catholic teaching on truth and lies, and the problem of telling the truth to a severely ill patient is discussed. It is suggested that the contemporary Catholic model of gradually telling a terminal patient the truth, which (...) looks reasonable and feasible in theory, is rarely followed in practice, as in the majority of cases the truth is not told tout court. Problems stem from the way in which medicine is currently practiced in Italy; from the synergism between Catholicism and the medical tradition's grounded paternalism; and from the ambiguity of the term ?hope?. Catholic ethics in fact recommends that the truth must be told without destroying hope, but the Catholic meaning of ?hope? is very different from its meaning in current language. (shrink)

Increasingly, the world seems to shrink due to our ever-expanding technological and communication capacities. Correspondingly, our awareness of other cultures increases. This is especially true in the field of bioethics because the technological progress of medicine throughout the world is causing dramatic and challenging intersections with traditionally held values. Think of the use of pregnancy monitoring technologies like ultrasound to abort fetuses of the “wrong” sex in India, the sale of human organs in and between countries, or the disjunction between (...) the haves and the have-nots in South America when it comes to bone marrow transplants, while thousands of other children die for want of fundamental goods and services like clean water, basic inoculations, and food itself. (shrink)

David Thomasma called for the development of a medical ethics based squarely on the philosophy of medicine. He recognized, however, that widespread anti-essentialism presented a significant barrier to such an approach. The aim of this article is to introduce a theory that challenges these anti-essentialist objections. The notion of natural kinds presents a modest form of essentialism that can serve as the basis for a foundationalist philosophy of medicine. The notion of a natural kind is neither static nor reductionistic. Disease (...) can be understood as making necessary reference to living natural kinds without invoking the claim that diseases themselves are natural kinds. The idea that natural kinds have a natural disposition to flourish as the kinds of things that they are provides a telos to which to tether the notion of disease – an objective telos that is broader than mere survival and narrower than subjective choice. It is argued that while nosology is descriptive and may have therapeutic implications, disease classification is fundamentally explanatory. Sickness and illness, while referring to the same state of affairs, can be distinguished from disease phenomenologically. Scientific and diagnostic fallibility in making judgments about diseases do not diminish the objectivity of this notion of disease. Diseases are things, not kinds. Injury is a concept parallel to disease that also makes necessary reference to living natural kinds. These ideas provide a new possibility for the development of a philosophy of medicine with implications for medical ethics. (shrink)

The President’s Council on Bioethics has addressed the moral status of human preembryos in its reports on stem cell research and human therapeutic cloning. Although the Council has been criticized for being hand-picked to favor the right-to-life viewpoint concerning human preembryos, it has embraced the idea that the right-to-life position should be defended in secular terms. This is an important feature of the Council’s work, and it demonstrates a recognition of the need for genuine engagement between opposing sides in the (...) debate over stem cell research. To promote this engagement, the Council has stated in secular terms several arguments for the personhood of human preembryos. This essay presents and critiques those arguments, and it concludes that they are unsuccessful. If the best arguments in support of the personhood of human preembryos have been presented by the Council, then there are no reasonable secular arguments in support of that view. (shrink)

This article addresses the impact of the potential conflict between the roles of physicians who are both clinicians and researchers on the recruitment of persons into research trials. It has been proposedthat a physician breaches inter-role confidentiality when he or she uses information gathered in his or her clinical role to inform patients about trials for which they may be eligible and that clinician-researchers should adopt a model of preliminary consent to be approached about research prior to commencing a clinical (...) relationship. This article argues that even if we grant the legitimacy of inter-role confidentiality (which is open to question), there are circumstances in which other obligations physicians bear override the obligation of inter-role confidentiality. Moreover, it is argued that the practice of preliminary consent is morally suspect and that such consent cannot be deemed valid. The article concludes with a series of recommendations of ways in which the legitimate concern regarding the conflicting roles of clinician-researchers can be addressed in the recruitment stage of research. (shrink)

Three Canadian institutional animal care and use committees were observed over a 1-year period to investigate animal ethical evaluation. While each protocol was evaluated, the observer collected information about the final decision, the type of protocol, and the category of invasiveness. The observer also wrote down verbatim all verbal interventions, which were coded according to the following categories: scientific, technical, politics, human analog, reduction, refinement, and replacement. The data revealed that only 16% of the comments were devoted to the 3 (...) explicit ethical categories and that most of the comments were technical. However, the analysis revealed that ethical concerns were implicit in both scientific and technical comments; either ethical norms had been translated into scientific and technical language, or some of the scientific and technical comments had an impact on the ethical treatment of animals. The results are discussed in relation to previous nonobservational research that identified potential pitfalls and bias in animal ethical evaluation. (shrink)

I argue that valid informed consent is ethically required for organ donation from individuals declared dead using neurological criteria. Current policies in the U.S. do not require this and, not surprisingly, current practices inhibit the possibility of informed consent. Relevant information is withheld, opportunities to ensure understanding and appreciation are extremely limited, and the ability to make and communicate a free and voluntary decision is hindered by incomplete disclosure and other practices. Current practices should be revised to facilitate valid informed (...) consent for organ donation. (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)

: Its promises to the contrary notwithstanding, bioethics is plural. There is a diversity of content-full moral understandings of the good and the right. Moreover, there is no secular means in principle to set this diversity aside without begging the question. This moral diversity exists both as a sociological condition and as a moral epistemological constraint. Without succumbing to a metaphysical scepticism or moral relativism, the bioethics of the future, if it is to be honest, should learn how to live (...) with robust moral diversity. (shrink)

The philosophers Peter Singer and Jeff McMahan hold variations of the view that infant interests in continued life are suspect because infants lack the cognitive complexity to anticipate the future. Since infants cannot see themselves as having a future, Singer argues that the future cannot have value for them, and McMahan argues that the future can only have minimal value for an infant. This paper critically analyzes these arguments and defends the view that infants can have interests in continuing to (...) live. Even though infants themselves lack a strong psychological connection to the future, others who are involved in an infant’s life can anticipate, on an infant’s behalf, the kind of future that awaits the infant, and on the basis of this insight judge that continuing to live would be in the infant’s interests. After defending this position, I argue that this position on the interests of infants in continued life does not commit one to opposing abortion, and it does not commit one to the view that our ethical obligations to protect the lives of sentient animals are the same as our ethical obligations to protect infant lives. (shrink)

Bioethics uses various theories, methods and institutions for its decision-making. Lately, a dialogical, i.e., dialogue-based, approach has been argued for in bioethics. The aim of this paper is to explore some of the decision-making processes that may be involved in this dialogical approach, as well as related pitfalls that may have to be addressed in order for this approach to be helpful, particularly in clinical ethics. Using informal logic, an analysis is presented of the notion of dialogue and of the (...) stages of dialogical decision-making, and then processes and related pitfalls associated with these stages in the context of clinical ethics are examined. The results of this exploration are expected to facilitate the implementation and empirical testing of dialogical bioethics. (shrink)

The origins of professional ethical codes and oaths are explored. Their legitimacy and usefulness within the profession are questioned and an alternative ethical source is suggested. This source relies on a commonly shared, naturally knowable set of principles known as common morality.

The notion of common morality plays a prominent role in some of the most influential theories of biomedical ethics. Here, I focus on Beauchamp and Childress’s models in the fourth and fifth edition of Principles of Biomedical Ethics as well as on a revision that Beauchamp proposed in a recent article. Although there are significant differences in these works that require separate analysis, all include a role for common morality as starting point and normative framework for theory construction in combination (...) with a coherence theory of moral justification. I defend to some extent the existence and empirical significance of common morality, as delineated by Beauchamp and Childress in different versions, but criticize its normative role. It is neither convincing as a moral foundation nor well compatible with a standard coherentist justification. I suggest that the authors should give up the foundational account for a more modest account of common morality as resource of well-established moral insights and experiences, which have proved generally valid but neither sufficient nor infallible. Beauchamp’s latest proposal appears as a step in this direction; indeed, it may be the beginning of the end of his common-morality theory. (shrink)

In Western democratic society, the specificity of the bioethical debate over the life-sciences involves bringing together many different study factors. The dilemmas raised by the new scientific discoveries highlight how contemporary common sense is plagued by a profound feeling of anguish over possible future anthropological developments. One of the central problems is the social construction of consent as a psychological strategy seeking to orient public opinion toward accepting new applications of science and technology. On the one hand, the general features (...) in the epistemological analysis of the mind-brain identity are called into question; and on the other, together with all those research directions concerned with the "meaning of life," we enter the dimension of the complex issue inherent in the possibility of establishing if there exists something transcending thought and what it may be. In both cases a problem is raised on which the meaning of human life and the world depend, while between the two universes described by medical science and ethical-philosophical thought a window of opportunity for important psychological research is opened. In order to understand such phenomena the present article defends the theory that social psychology must adopt as its subject matter "thinking society," that is, society characterized by discussion and reasoning on themes relevant to bioethics. (shrink)

What is Christian about Christian bioethics? The short answer to this question is that the Incarnation should shape the form and content of Christian bioethics. In explicating this answer it is argued that contemporary medicine is unwittingly embracing and implementing the transhumanist dream of transforming humans into posthumans. Contemporary medicine does not admit that there are any limits in principle to the extent to which it should intervene to improve the quality of human life. This largely inarticulate, yet ambitious, agenda (...) is derived first in late modernity's failed, but nonetheless ongoing, attempt to transform necessity into goodness, and second the loss of any viable concept of eternity, thereby stripping temporal existence of any normative significance. In short, medicine has become the vanguard of a profane attempt to save humankind by extracting data from flesh. In response, it is contended that an alternative Christian bioethics must be shaped by the Incarnation, the Word made flesh. This assertion does not entitle Christians to oppose the posthuman trajectory of contemporary medicine on the basis of any natural or biological essentialism. Rather, it is an evangelical witness to the grace of Christ's redemption instead of the work of self-transformation. It is Christ alone who thereby makes the vulnerability and mortality of finitude a gift and blessing. Specifically, it is maintained that the chasm separating necessity and goodness cannot be filled but only bridged through the suffering entailed in Christ's cross, and through Christ's resurrection eternity becomes the standard against which the temporal lives of human creatures are properly formed and measured. Consequently, Christian bioethics should help us become conformed to Christ rather than enabling selftransformation. (shrink)

In the West, mainstream bioethicists tend to appreciate intimate relationships as a hindrance to individual autonomy. Scholars have even argued against approaching a mother to donate a kidney to save the life of her child; the request, they claim, is too manipulative and, thereby, violates her autonomy. For Chinese bioethicists, such a moral analysis is absurd. The intimate relationship between mother and child establishes strong mutual obligations. It creates mutual moral responsibilities that often require sacrifices for each other. This paper (...) argues that while aiding others is a moral duty, helping one’s family is a much stronger duty and poses no threat to one’s autonomy. For Confucianism, empathetic intimate feelings, the heart and mind of ren, rest at the root of morality. It requires that we, as moral beings, assume duties to relieve the suffering of others. The more intimate the relationship the stronger the obligation to assist. The family is a closely knitted moral community. Family members often share living resources, mutual experiences, and a sense of identity. Family members act as a social unit, and, ordinarily, mutual obligations among members have priority over duties to those outside of the family. For Confucian bioethics, family-based consent to medical treatment is regarded as natural and reasonable. Family-based decision making is a taken-for-granted norm of social life. While close family members have priority, Confucianism extends such obligations outward toward members of the extended family and the society at large. There is a general principle of gradation of love, which reflects different degrees of personal intimacy and, therefore, of moral obligation. In this fashion, Confucianism seeks to treat the whole of society as one extended family. Hence, in bioethics, mutual responsibility and family-based consent are regarded as basic principles. Through a series of case discussions, this paper illustrates that atomistic individual-based autonomy offers but a poor response to bioethical issues. (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?

In order to reflect on the morality of the health care market this paper critiques some of H. T. Engelhardt's presuppositions. Engelhardt has created the vivid term ‘moral stranger’ and suggested that there can be a ‘morality of moral strangers’. However his position relies either on certain necessary presuppositions which he leaves unmentioned or on presuppositions that are—in a strict sense—not moral ones. Engelhardt advocates the market economy as the guiding principle of health care, and claims that the market needs (...) no moral presuppositions. But when the preconditions of a functioning market are examined it turns out that a functioning market requires property and ownership, and that property and ownership are moral institutions. Therefore the application of the idea of the market to health care undoubtedly has morally serious consequences: most important, the difference between commodities and human beings is obscured. (shrink)

Timothy Murphy argues in his article “In Defense of Irreligious Bioethics” (2012) that the role of religion in normative bioethics should be limited and that a viable means for limiting its role (o...

This paper examines the concept of ‘openness with patients’ from the stand-point of the limitations of biomedical ethics. Initially we review contemporary critiques of bioethics and, in particular, of principlism; we relate how other; somewhat neglected, forms of medical ethics can yield useful information and provide moral guidance.The main section of the paper then shows how a bioethical approach to openness misses the social context in our example, the viewpoints of patients; we present some of the increasing wealth of research (...) evidence which points towards patients wanting more information and a greater degree of openness.Finally we put forward that a principlist’s objection to active encouragement of openness might be based on the risk of infringing upon the ‘right not to know’. We reject this by arguing how rights can be trumped. (shrink)

Prenatal care and the practice of prenatal genetic testing are about to be changed fundamentally. Due to several ground-breaking technological developments prenatal screening and diagnosis (PND) will soon be offered earlier in gestation, with less procedure-related risks and for a profoundly enlarged variety of targets. In this paper it is argued that the existing normative framework for prenatal screening and diagnosis cannot answer adequately to these new developments. In concentrating on issues of informed consent and the reproductive autonomy of the (...) pregnant women the ethical debate misses problems related to the clinical pathway as a whole and to implicit normative attributions to clinical actions or the function of health care professionals. If, however, ethical debate would focus on the clinical context and on the ends of PND to a larger extent, it would be able to provide a more comprehensive analysis of the ethical challenges especially of the new technologies in order to be more adequately prepared for their implementation. (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)