People’s health is hugely affected by where they live, their occupational status and their socio-economic position. It has been widely argued that the presence of such social determinants in health provides good reasons to reject luck egalitarianism as a theory of distributive justice in health. The literature provides different reasons why this responsibility-sensitive theory of distributive justice should not be applied to health. The critiques submit that the social circumstances undermine or remove people’s responsibility for their health; responsibility sensitive health (...) policies would adversely affect those who are worst off and; the luck egalitarian approach to health distracts from the important task of rectifying socio-economic influences on people's health and provides individualistic solutions to collective problems. But for each of these variants of the critique luck egalitarianism provides suitable answers. The literature on social determinants is no detriment to the project of applying luck egalitarianism to health. (shrink)

The curious philosopher often answers questions by raising further, more fundamental questions. How can this be fruitful and practical in the context of Wageningen University? Philosophy offers critical reflection on conceptual and normative assumptions in science and society, and that is necessary for responsible practices. I illustrate this by analyzing the concept of quality of life – a key value in the mission of our university – and by questioning current debates about responsibility for health.

Debates over vaccine mandates raise intense emotions, as reflected in the current controversy over whether to mandate the vaccine against human papilloma virus (HPV), the virus that can cause cervical cancer. Public health ethics so far has failed to facilitate meaningful dialogue between the opposing sides. When stripped of its emotional charge, the debate can be framed as a contest between competing ethical values. This framework can be conceptualized graphically as a conflict between autonomy on the one hand, which militates (...) against government intrusion, and beneficence, utilitarianism, justice, and nonmaleficence on the other, which may lend support to intervention. When applied to the HPV vaccine, this framework would support a mandate based on utilitarianism, if certain conditions are met and if herd immunity is a realistic objective. (shrink)

The problem of standard of care in clinical research concerns the level of treatment that investigators must provide to subjects in clinical trials. Commentators often formulate answers to this problem by appealing to two distinct types of obligations: professional obligations and natural duties. In this article, I investigate whether investigators also possess institutional obligations that are directly relevant to the problem of standard of care, that is, those obligations a person has because she occupies a particular institutional role. I examine (...) two types of institutional contexts: (1) public research agencies – agencies or departments of states that fund or conduct clinical research in the public interest; and (2) private-for-profit corporations. I argue that investigators who are employed or have their research sponsored by the former have a distinctive institutional obligation to conduct their research in a way that is consistent with the state's duty of distributive justice to provide its citizens with access to basic health care, and its duty to aid citizens of lower income countries. By contrast, I argue that investigators who are employed or have their research sponsored by private-for-profit corporations do not possess this obligation nor any other institutional obligation that is directly relevant to the ethics of RCTs. My account of the institutional obligations of investigators aims to contribute to the development of a reasonable, distributive justice-based account of standard of care. (shrink)

Should there be a female age limit on public funding for assisted reproductive technology (ART)? The question bears significant economic and sociopolitical implications and has been contentious in many countries. We conceptualise the question as one of justice in resource allocation, using three much-debated substantive principles of justice—the capacity to benefit, personal responsibility, and need—to structure and then explore a complex of arguments. Capacity-to-benefit arguments are not decisive: There are no clear cost-effectiveness grounds to restrict funding to those older women (...) who still bear some capacity to benefit from ART. Personal responsibility arguments are challenged by structural determinants of delayed motherhood. Nor are need arguments decisive: They can speak either for or against a female age limit, depending on the conception of need used. We demonstrate how these principles can differ not only in content but also in the relative importance they are accorded by governments. Wide variation in ART public funding policy might be better understood in this light. We conclude with some inter-country comparison. New Zealand and Swedish policies are uncommonly transparent and thus demonstrate particularly well how the arguments we explore have been put into practice. (shrink)

In the last two decades, the term “quality-of-life” has become popular in medicine and health care. There are, however, important differences in the meaning and the use of the term. The message of all quality-of-life talk is that medicine and health care are not valuable in themselves. They are valuable to the extent that they contribute to the quality of life of patients. The ultimate aims of medicine and health care are not health or prolongation of life as such, but (...) preservation or improvement of the quality of life. The primary aims of medicine and health care, such as the prolongation of life, can – but need not always – come into conflict with the ultimate ones: medical treatments do not always benefit a patient. In this article I will, first, summarize the results of my explorations of the use and the meaning of the term “quality-of-life.” The use and the meaning of the term turn out to depend on the contexts of medical decisionmaking in which it is used. I will show that there are at least three different concepts of quality-of-life. Second, I will argue that the different concepts of quality-of-life are not unrelated. They point to different components of and/or conditions for happiness. Third, I will analyze the relation between the three concepts of qualityof-life, health and happiness. (shrink)

I argue for a conception of health as a person's ability to achieve or exercise a cluster of basic human activities. These basic activities are in turn specified through free-standing ethical reasoning about what constitutes a minimal conception of a human life with equal human dignity in the modern world. I arrive at this conception of health by closely following and modifying Lennart Nordenfelt's theory of health which presents health as the ability to achieve vital goals. Despite its strengths I (...) transform Nordenfelt's argument in order to overcome three significant drawbacks. Nordenfelt makes vital goals relative to each community or context and significantly reflective of personal preferences. By doing so, Nordenfelt's conception of health faces problems with both socially relative concepts of health and subjectively defined wellbeing. Moreover, Nordenfelt does not ever explicitly specify a set of vital goals. The theory of health advanced here replaces Nordenfelt's (seemingly) empty set of preferences and society-relative vital goals with a human species-wide conception of basic vital goals, or ‘central human capabilities and functionings’. These central human capabilities come out of the capabilities approach (CA) now familiar in political philosophy and economics, and particularly reflect the work of Martha Nussbaum. As a result, the health of an individual should be understood as the ability to achieve a basic cluster of beings and doings—or having the overarching capability, a meta-capability, to achieve a set of central or vital inter-related capabilities and functionings. (shrink)

The gendered division of labor is the major cause of gender inequality with respect to the broad spectrum of resources, occupations, and roles. Although many feminists aspire to an equality of outcome where there are no significant patterns of gender difference across these dimensions, many have also argued that liberal theories of social justice do not have the conceptual tools to justify a direct attack on the gendered division of labor. Indeed, many critics argue that liberalism positively condones it, presuming (...) that it arises from the free choices of individuals, which must be respected. In this paper I will accept the feminist goal of equality of outcome across roles, occupations, income, and wealth, but will argue that liberal theories of justice are consistent with strong measures aimed at promoting such equality. I will show that liberalism has the conceptual resources to justify a concrete policy measure that goes considerably beyond the measures usually championed by feminists. The example I focus on is “daddy quotas,” which refers to the tagging of a significant part of parental leave for the exclusive use of fathers. (shrink)

According to HealthCare.gov, by improving access to quality health for all Americans, the Affordable Care Act (ACA) will reduce disparities in health insurance coverage. One way this will happen under the provisions of the ACA is by creating a new health insurance marketplace (a health insurance exchange) by 2014 in which “all people will have a choice for quality, affordable health insurance even if a job loss, job switch, move or illness occurs”. This does not mean that everyone will have (...) whatever insurance coverage he or she wants. The provisions of the ACA require that each of the four benefit categories of plans (known as bronze, silver, gold and platinum) provides no less than the benefits available in an “essential health benefits package”. However, without a clear understanding of what criteria must be satisfied for health care to be essential, the ACA’s requirement is much too vague and open to multiple, potentially conflicting interpretations. Indeed, without such understanding, in the rush to provide health insurance coverage to as many people as is economically feasible, we may replace one kind of disparity (lack of health insurance) with another kind of disparity (lack of adequate health insurance). Thus, this paper explores the concept of “essential benefits”, arguing that the “essential health benefits package” in the ACA should be one that optimally satisfies the basic needs of the people covered. (shrink)

This review article of Shlomi Segall's Health, Luck, and Justice (Princeton University Press, 2010) addresses three issues: first, Segall’s claim that luck egalitarianism, properly construed, does not object to brute luck equality; second, Segall’s claim that brute luck is properly construed as the outcome of actions that it would have been unreasonable to expect the agent to avoid; and third, Segall’s account of healthcare and criticism of rival views. On the first two issues, a more conventional form of luck egalitarianism (...) – that is, one which objects to brute luck even if it creates equality, and which construes brute luck as the inverse of agent responsibility – is defended. On the third issue, strengths and weaknesses in Segall’s criticism of Rawlsian, democratic egalitarian, and all-luck egalitarian approaches to healthcare, and in his own luck egalitarian approach, are identified. (shrink)

The principle of fair equality of opportunity is regularly used to justify social policies, both in the philosophical literature and in public discourse. However, too often commentators fail to make explicit just what they take the principle to say. A principle of fair equality of opportunity does not say anything at all until certain variables are filled in. I want to draw attention to two variables, timing and currency. I argue that once we identify the few plausible ways we have (...) at our disposal for filling in those variables, it will become apparent that a reasonable version of the principle will be quite narrow. Its usefulness as a justificatory basis for social policies will be limited to those policies that target the distribution of competitive opportunities among people entering majority. (shrink)

In discussions of the ethics of human gene therapy, it has become standard to draw a distinction between the use of human gene transfer techniques to treat health problems and their use to enhance or improve normal human traits. Some dispute the normative force of this distinction by arguing that it is undercut by the legitimate medical use of human gene transfer techniques to prevent disease - such as genetic engineering to bolster immune function, improve the efficiency of DNA repair, (...) or add cellular receptors to capture and process cholesterol. If disease prevention is a proper goal of medicine, these critics argue, and the use of gene transfer techniques to enhance human health maintenance capacities will help achieve that goal, then the “treatment/enhancement‘ distinction cannot define the limits of legitimate gene therapy. In this paper, I argue that a line can be drawn between prevention and enhancement for gene therapy (and thus between properly medical and nonmedical uses of gene therapy), but only if one is willing to accept two rather old-fashioned claims: 1) Some health problems are best understood as if they were entities in their own right, reifiable as processes or parts in a biological system, with at least as much ontological objectivity and theoretical significance as the functions that they inhibit. 2) Legitimate preventive genetic health care should be limited to efforts to defend people from attack by these more robust pathological entities, rather than changing their bodies to evade social injustices. (shrink)

One-third of all human lives end in early death from poverty-related causes. Most of these premature deaths are avoidable through global institutional reforms that would eradicate extreme poverty. Many are also avoidable through global health-system reform that would make medical knowledge freely available as a global public good. The rules should be redesigned so that the development of any new drug is rewarded in proportion to its impact on the global disease burden (not through monopoly rents). This reform would bring (...) drug prices down worldwide close to their marginal cost of production and would powerfully stimulate pharmaceutical research into currently neglected diseases concentrated among the poor. Its feasibility shows that the existing medical-patent regime (trade-related aspects of intellectual property rights—TRIPS—as supplemented by bilateral agreements) is severely unjust—and its imposition a human-rights violation on account of the avoidable mortality and morbidity it foreseeably produces. (shrink)

Christopher Boorse's Bio Statistical Theory (BST) defines health as the absence of disease, and disease as the adverse departure from normal species functioning. This paper presents a two-pronged problem for this account. First I demonstrate that, in order to accurately account for dynamic physiological functions, Boorse's account of normal function needs to be modified to index functions against situations. I then demonstrate that if functions are indexed against situations, the BST can no longer account for diseases that result from specific (...) environmental factors. The BST is impaled on either horn of this dilemma and therefore must be dismissed. (shrink)

This paper examines the fairness of avoidable inequalities in health. It contrasts two approaches to this question, a direct approach and an indirect approach. Most of the discussion focuses on the indirect approach advocated by Daniels, Kennedy and Kawachi (2000). Their argument that avoidable inequalities in health are not unfair when their causes are otherwise fair is criticised on two counts. First, it encounters a surprising difficulty when one attends carefully to the point at which ethics intersects with epidemiology here. (...) Second, it fails to address the fundamental issue, which is whether any version of the direct approach is valid. (shrink)

Department of Political Studies, Queen's University, 99 University Avenue, Kingston, Ontario, Canada, K7L 3N6. Email: farrelly{at}queensu.ca ' + u + '@' + d + ' '//--> Abstract Should we invest more public funding in basic aging research that could lead to medical interventions that permit us to safely and effectively retard human aging? In this paper I make the case for answering in the affirmative. I examine, and critique, what I call the Fairness Objection to making aging research a greater (...) priority than it currently is. The Fairness Objection presumes that support for aging research is limited to a simplistic utilitarian justification. That is, a mode of justification that is aggregative and permits imposing high costs on a few so that small benefits could be enjoyed by numerous recipients. I develop two arguments to refute the Fairness Objection. The Fairness Objection mischaracterizes the utilitarian argument for retarding human aging. It does so by invoking the fallacious conceptual distinction between "saving lives" and "extending lives", as well as making a number of mistaken assumptions concerning the likely benefits of retarding human aging. Secondly, I argue that the case for tackling aging can be made on contractualist , in addition to utilitarian, grounds. Because the harms of senescence are "morally relevant" to the harms of disease, contractualists can permit aggregation within lives. And thus no one could reasonably reject, I contend, a principle that makes the aspiration to tackle human aging more of a priority than it currently is. CiteULike Connotea Del.icio.us What's this? (shrink)

Advances in psychopharmacology raise the prospects of enhancing neurocognitive functions of humans by improving attention, memory, or mood. While general ethical reflections on psychopharmacological enhancement have been increasingly published in the last years, ethical criteria characterizing physicians’ role in neurocognitive enhancement and guiding their decision-making still remain highly unclear. Here it will be argued that also in the medical domain the use of cognition-enhancing drugs is not intrinsically unethical and that, in fact, physicians should assume an important role in gating (...) their usage. For finding normative orientation, concepts of disease, normality or medicine will not be helpful since—due to their cryptonormative nature—they rather hamper than allow targeted discussion and decision-making. As an alternative, the common and widely accepted bioethical criteria of beneficence, non-maleficence, autonomy and distributive justice allow a clinically applicable, highly differentiated context- and case-sensitive approach. By embedding decision-making in a participative physician–patient relationship extrinsic objections against neurocognitive enhancement (e.g. invalid perceptions about efficacy, benefit or risk; questionable voluntariness; restrained decision-making capacity) can be curtailed. (shrink)

Accounts of the concepts of function and dysfunction have not adequately explained what factors determine the line between low‐normal function and dysfunction. I call the challenge of doing so the line‐drawing problem. Previous approaches emphasize facts involving the action of natural selection (Wakefield 1992a, 1999a, 1999b) or the statistical distribution of levels of functioning in the current population (Boorse 1977, 1997). I point out limitations of these two approaches and present a solution to the line‐drawing problem that builds on the (...) second one. (shrink)

Considerations of autonomy and independence, properly understood, support strictly egalitarian provision of necessary medical treatment. If the financially better-off can purchase access to necessary medical treatments that the financially less well-off cannot purchase without help, then their discretionary power to give or to withhold monetary gifts indirectly gives them the power to make life-and-death or sickness-and-health decisions for others. To prevent private citizens from having this objectionable form of power, government must ensure that citizens’ finances do not affect their access (...) to medical treatments that significantly prolong life, relieve suffering, or cure or mitigate disabilities. Government should ensure this even if doing so involves leveling down and even if it is unclear whether egalitarian provision of necessary treatment would provide better care to the poor than a less egalitarian health care system would. (shrink)

With by far the lowest population density in the United States, myriad challenges attach to healthcare delivery in Alaska. In the “Size, Population, and Accessibility” section, we characterize this geographic context, including how it is exacerbated by lack of infrastructure. In the “Distributing Healthcare” section, we turn to healthcare economics and staffing, showing how these bear on delivery—and are exacerbated by geography. In the “Health Care in Rural Alaska” section, we turn to rural care, exploring in more depth what healthcare (...) delivery looks like outside of Alaska’s major cities. This discussion continues in the “Alaska’s Native Villages” section, which specifically analyzes healthcare in Alaska’s indigenous villages, some of the smallest and most isolated communities in the United States. Though many of the ways we could improve Alaskan health care for Alaskan residents are limited by its unique features, the “Justice and Healthcare Delivery” and “Technology and Telemedicine” sections consider ways in which certain policies and technology—including telemedicine—could mitigate the challenges developed in previous sections. (shrink)

The range of opportunities people enjoy in life largely depends on social, biological, and genetic factors for which individuals are not responsible. Philosophical debates about equality of opportunities have focussed mainly on addressing social determinants of inequalities. However, the introduction of human bioenhancement should make us reconsider what our commitment to equality entails. We propose a way of improving morally relevant equality that is centred on what we consider a fair distribution of bioenhancements. In the first part, we identify three (...) main positions in the debate on bioenhancement and equality, and we show how each of them fails to meet the demands of a serious commitment to equality. In the second part, we formulate a new proposal that we think better promotes equality of opportunities: people from disadvantaged socio-economic backgrounds should be given access to bioenhancements while people from privileged socio-economic background should be prohibited from using them. We argue that those who are concerned about the inequality implications of bioenhancement should embrace this solution, rather than reject bioenhancement. (shrink)

For more than two decades, classes on “professionalism” have been the dominant platform for the non-technical socialization of medical students. It thus subsumes elements of previous foundation courses in bioethics and “medicine and society” in defining the appropriate relation between practitioners, patients, and society-at-large. Despite its importance, there is, however, no clear definition of what “professionalism” entails or the manner in which it serves various purported goals. This essay reviews, first, the historical role of the vocational practitioner in society, and (...) second, the introduction of “professionalism” as a newly constituted, core value in teaching. The structure of the paper is as an archaeology, a Foucauldian term for an investigation of seemingly separate but related antecedent contexts and ideas whose result is a perspective or point of view. The goal thus is an attempt to precisely locate “professionalism” within the greater history of medicine and its contemporary role in medical socialization. (shrink)

This article argues that diverse theorists have reasons to theorize about fairness in nonideal conditions, including theorists who reject fairness in ideal theory. It then develops a new all-purpose model of ‘nonideal fairness.’ §1 argues that fairness is central to nonideal theory across diverse ideological and methodological frameworks. §2 then argues that ‘nonideal fairness’ is best modeled by a nonideal original position adaptable to different nonideal conditions and background normative frameworks (including anti-Rawlsian ones). §3 then argues that the parties to (...) the model have grounds to seek a variety of remedial social, legal, cultural, and economic ‘nonideal primary goods’ for combating injustice, as well as grounds to distribute these goods in an equitable and inclusive manner. Finally, I illustrate how the model indexes the nonideal primary goods it justifies to different nonideal contexts and background normative frameworks, illustrating why diverse theorists should find the model and its output principles attractive. (shrink)

Various U.S. laws, such as the Clean Air Act and the Food Quality Protection Act, require additional protections for susceptible subpopulations who face greater environmental health risks. The main ethical rationale for providing these protections is to ensure that environmental health risks are distributed fairly. In this article, we (1) consider how several influential theories of justice deal with issues related to the distribution of environmental health risks; (2) show that these theories often fail to provide specific guidance concerning policy (...) choices; and (3) argue that an approach to public decision making known as accountability for reasonableness can complement theories of justice in establishing acceptable environmental health risks for the general population and susceptible subpopulations. Since accountability for reasonableness focuses on the fairness of the decision-making process, not the outcome, it does not guarantee that susceptible subpopulations will receive a maximum level of protection, regardless of costs or other morally relevant considerations. (shrink)

Citizens in wealthy liberal democracies are typically expected to see to basic needs like food, clothing, and shelter out of their own income, and those without the means to do so usually receive assistance in the form of cash transfers. Things are different with health care. Most liberal societies provide their citizens with health care or health care insurance in kind, either directly from the state or through private insurance companies that are regulated like public utilities. Except perhaps for small (...) co-pays or deductibles, citizens are not expected to see to their health needs out-of-pocket, at least for some basic level of care. Instead, when a citizen gets sick, the state or her insurance company foots the... (shrink)

This essay defends the controversial and indeed counterintuitive claim that there is a good argument to be made from a Lockean perspective for government action to guarantee access to health care. The essay maintains that this argument is in some regards more robust than the well-known argument in defense of universal health care spelled out by Norman Daniels, which this essay also examines in some detail. Locke's view that government should protect people's lives, property, and freedom–where freedom is understood as (...) independence and self-determination–justifies government action to ensure access to health care, because (roughly), just as individuals cannot protect themselves from crime and foreign invasion, so individuals are unable to provide for their own health care. Defense from disease is as important as defense from crime, and–although this is arguable–government action to guarantee access to health care does not itself undermine freedom. (shrink)

Many hold that distributing healthcare according to medical need is a requirement of equality. Most egalitarians believe, however, that people ought to be equal on the whole, by some overall measure of well-being or life-prospects; it would be a massive coincidence if distributing healthcare according to medical need turned out to be an effective way of promoting equality overall. I argue that distributing healthcare according to medical need is important for reducing individuals' uncertainty surrounding their future medical needs. In other (...) words, distributing healthcare according to medical need is a natural feature of healthcare insurance; it is about indemnity, not equality. (shrink)

An ‘ideal’ health care system would be unencumbered by economic considerations and provide an ample supply of well-paid health care professionals who would supply culturally appropriate optimal health care to the level desired by patients. An ‘ideal’ health care system presupposes an ‘ideal’ society in which resources for all social goods are unlimited. Changes within health care systems occur both because of changes within the system and because of changes or demands in and by the ‘exterior environment’. Social systems must (...) be in a homeostatic balance. If one component fails to accommodate itself to other forces, needs and interests within the system, the system is imperiled. It is difficult to create a just health care system in an unjust society, just as it is difficult to practise truly ethical medicine in an ethically corrupt system. (shrink)

The enhancement debate in neuroscience and biomedical ethics tends to focus on the augmentation of certain capacities or functions: memory, learning, attention, and the like. Typically, the point of contention is whether these augmentative enhancements should be considered permissible for individuals with no particular “medical” disadvantage along any of the dimensions of interest. Less frequently addressed in the literature, however, is the fact that sometimes the _diminishment_ of a capacity or function, under the right set of circumstances, could plausibly contribute (...) to an individual's overall well-being: more is not always better, and sometimes less is more. Such cases may be especially likely, we suggest, when trade-offs in our modern environment have shifted since the environment of evolutionary adaptation. In this article, we introduce the notion of “diminishment as enhancement” and go on to defend a _welfarist_ conception of enhancement. We show how this conception resolves a number of definitional ambiguities in the enhancement literature, and we suggest that it can provide a useful framework for thinking about the use of emerging neurotechnologies to promote human flourishing. (shrink)

This paper sets out to defend human genetic engineering with a new bioethical approach, post-humanism, combined with a radical democratic political framework. Arguments for the restriction of human genetic engineering, and specifically germ-line enhancement, are reviewed. Arguments are divided into those which are fundamental matters of faith, or "bio-Luddite" arguments, and those which can be addressed through public policy, or "gene-angst" arguments.The four bio-Luddite concerns addressed are: Medicine Makes People Sick; There are Sacred Limits of the Natural Order; Technologies Always (...) Serve Ruling Interests; The Genome is Too Complicated to Engineer. I argue that these are matters of faith that one either accepts or rejects, and that I reject.The non-fundamentalist or pragmatic concerns I discuss are: Fascist Applications; The Value of Genetic Diversity; The Geneticization of Life; Genetic Discrimination and Confidentiality; Systematically Bad Decisions by Parents; Discrimination Against the Disabled; Unequal Access; The Decline of Social Solidarity. I conclude that all these concerns can be adequately addressed through a proactive regulative framework administered by a liberal democratic state. Therefore, even germ-line genetic enhancement should eventually made available since the potential benefits greatly outweigh the potential risks. (shrink)

Recent articles published in this journal have highlighted the shortcomings of individualistic approaches to health promotion, and the potential contributions of relational analyses of autonomy to public health ethics. I argue that the latter helps to elucidate the former, by showing that an inadequate analysis of autonomy leads to misassignment of both forward-looking and backward-looking responsibility for health outcomes. Health promotion programmes predicated on such inadequate analyses are then ineffective, because they assign responsibility to agents whose social environment inhibits their (...) ability to act on such responsibilities; inequitable, because the social barriers to autonomous agency display a socio-economic gradient; and stigmatizing, because they license blaming of individuals for their own poor health without taking into account how reasonable it is to hold these individuals responsible, given the social barriers to autonomy they face. I further sketch how incorporating a relational understanding of autonomy could help to produce health promotion programmes that do not succumb to these difficulties, while avoiding coercive paternalism, exploring potential applications in ecological approaches to health promotion. (shrink)

“Neurodiversity” is associated with the struggle for the civil rights of all those diagnosed with neurological or neurodevelopmental disorders. Two basic approaches in the struggle for what might be described as “neuro-equality” are taken up in the literature: There is a challenge to current nosology that pathologizes all of the phenotypes associated with neurological or neurodevelopmental disorders ); there is a challenge to those extant social institutions that either expressly or inadvertently model a social hierarchy where the interests or needs (...) of individuals are ranked relative to what is regarded as properly functioning cognitive capacities. In this paper, we explore some of the reasons justifying which make it an important tool for achieving greater neuro-equality, while still recognizing its limitations for achieving this goal. Particularly, we explore how an appeal to functionality and neurological diversity can support a re-seeing of at least certain forms of ASD. (shrink)

Attention to individual choice is a valuable dimension of public health policy; however, the creation of effective public health programmes requires policy makers to address the material and social structures that determine a person’s chance of actually achieving a good state of health. This statement summarizes a well understood and widely held view within public health practice. In this article, we (i) argue that advocates for public health can and should defend this emphasis on ‘structures’ by reference to citizen autonomy (...) and not simply by emphasizing concern for counter-balancing values such as ‘population health’ or ‘fairness’, (ii) map and critically explore the contrasting conceptions of autonomy that feature in such debates, with particular attention to conceptions of autonomy that might feature in the defence of an emphasis on structures. We draw on (i) a relational conception of autonomy and (ii) the distinction that can be made between autonomous deliberation and autonomous action to suggest that offering people the opportunity to make choices about their health without also supporting their capability to achieve the object of these choices falls short of what is often considered to be morally and politically important about promoting autonomy in relation to health. (shrink)

Sowohl im System der medizinischen Versorgung als auch im Rahmen der Präventions- und Gesundheitsförderungspolitik stellt sich die Frage, welche Bedeutung dem Grundsatz der Eigenverantwortung zukommt. Der Beitrag vergleicht die Diskussionen in beiden Bereichen und stellt abschließend ihren Zusammenhang dar.

This paper seeks to define and delimit the scope of the social responsibilities of health professionals in reference to the concept of a social contract. While drawing on both historical data and current empirical information, this paper will primarily proceed analytically and examine the theoretical feasibility of deriving social responsibilities from the phenomenon of professionalism via the concept of a social contract.

Balfe argues against enhanced interrogation. He particularly focuses on the involvement of U.S. healthcare professionals in enhanced interrogation. He identifies several empirical and normative factors and argues that they are not good reasons to morally justify enhanced interrogation. I argue that his argument can be improved by making two points. First, Balfe considers the reasoning of those healthcare professionals as utilitarian. However, careful consideration of their ideas reveals that their reasoning is consequential rather than utilitarian evaluation. Second, torture is a (...) serious human rights abuse. When healthcare professionals become involved in enhanced interrogation, they violate not only human rights against torture but also human rights to health. Considering the consequential reasoning against human rights abuses, healthcare professionals’ involvement in enhanced interrogation is not morally justified. Supplementing Balfe’s position with these two points makes his argument more complete and convincing, and hence it can contribute to the way which shows that enhanced interrogation is not justified by consequential evaluation. (shrink)

Disability activists have sometimes claimed their disability has actually increased their well-being. Some even say they would reject a cure to keep these gains. Yet, these same activists often simultaneously propose improvements to the quality and accessibility of assistive technology. However, for any argument favoring assistive over curative technology to work, there must be a coherent distinction between the two. This line is already vague and will become even less clear with the emergence of novel technologies. This paper asks and (...) tries to answer the question: what is it about the paradigmatic examples of curative and assistive technologies that make them paradigmatic and how can these defining features help us clarify the hard cases? This analysis will begin with an argument that, while the common views of this distinction adequately explain the paradigmatic cases, they fail to accurately pick out the relevant features of those technologies that make them paradigmatic and to provide adequate guidance for parsing the hard cases. Instead, it will be claimed that these categories of curative or assistive technologies are defined by the role the technologies play in establishing a person’s relational narrative identity as a member of one of two social groups: disabled people or non-disabled people. (shrink)

In a series of recent papers, I have made three arguments about how to define “disease” and evaluate and apply possible definitions. First, I have argued that definitions should not be seen as traditional conceptual analyses, but instead as proposals about how to define and use the term “disease” in the future. Second, I have pointed out and attempted to address a challenge for dysfunction-requiring accounts of disease that I call the “line-drawing” problem: distinguishing between low-normal functioning and dysfunctioning. Finally, (...) I have used a dysfunction-requiring approach to argue that some extremely prevalent conditions, such as high blood pressure, high cholesterol, and ductal carcinoma in situ, are not diseases, but instead are risk factors. Four of the papers in this issue directly engage my previous work. In this commentary, I applaud the advances these authors make, address points of disagreement, and make suggestions about where the discussion should go next. (shrink)

Recent health legislation in Norway significantly increases access to specialist care within a legally binding time frame. The paper describes the contents of the new legislation and introduces some of the challenges with proliferations of rights to health care. The paper describes some of the challenges associated with the proliferation of legal rights to health care. It explains the benefits of assessing the new law in the light of a rights framework. It then analyses the problematic aspects of establishing additional (...) priority rules as solutions to rights conflicts. It then defends adequacy criteria for acceptable priority rules when such rules are unavoidable. It finally defends our proposed method and explores concrete applications. (shrink)

This essay examines the citizen's apparent agelessness that is foundational to liberal democratic theories. By engaging the notion of citizenship rights, Lanoix challenges this assumed perpetual adulthood and argues for a new way of conceptualizing the citizen. The broader notion of citizen as cohabitant allows for the changing relationship a citizen will have with her citizenship rights and accommodates individuals who are not self-governing but who, nonetheless, share a democratic space.

Palliative care serves both as an integrated part of treatment and as a last effort to care for those we cannot cure. The extent to which palliative care should be provided and our reasons for doing so have been curiously overlooked in the debate about distributive justice in health and healthcare. We argue that one prominent approach, the Rawlsian approach developed by Norman Daniels, is unable to provide such reasons and such care. This is because of a central feature in (...) Daniels' account, namely that care should be provided to restore people's opportunities. Daniels' view is both unable to provide pain relief to those who need it as a supplement to treatment and, without justice-based reasons to provide palliative care to those whose opportunities cannot be restored. We conclude that this makes Daniels' framework much less attractive. (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)

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)

Is there a rational and ethical basis for efforts to rescue individuals in dire straits? When does rescue have ethical support, and when does it reflect an irrational impulse? This paper defines a Rule of Rescue and shows its intuitive appeal. It then proceeds to argue that this rule lacks support from standard principles of justice and from ethical principles more broadly, and should be rejected in many situations. I distinguish between agent-relative and agent-neutral reasons, and argue that the Rule (...) of Rescue qualifies only in a narrow range of cases where agent-relative considerations apply. I conclude that it would be wise to set aside the Rule of Rescue in many cases, especially those involving public policies, where it has only weak normative justification. The broader implications of this analysis are noted. (shrink)