Political theorists generally defend the moral importance of health care by appealing to its purported importance in promoting good health and saving lives. Recent research on the social determinants of health demonstrates, however, that health care actually does relatively little to promote good health or save lives in comparison with other social and environmental factors. This article assesses the implications of the social determinants of health literature for existing theories of health care justice, and outlines a new approach that can (...) justify publicly subsidized comprehensive health care despite its limited contribution to good health. Even if health care plays a relatively limited role in promoting good health, it remains morally important because of the care it provides to individuals. As such, it can be justified in terms of care ethics. When health care is justified primarily in terms of care rather than health, however, the goals of a just health-care system shift. The measure of a just health-care system is no longer strictly its ability to generate good health outcomes but also its ability to provide individuals with accessible, good quality daily care. This different focus has important consequences for the way we think about the institutions of a just health-care system as well as for the delivery and allocation of medical goods and services. (shrink)

This article investigates what notions of “just health care” are found at three Swedish hospitals among health care personnel and whether these notions are relevant to what priorities are actually made. Fieldwork at all three hospitals and 114 in-depth interviews were conducted. Data have been subject to conceptual and ethical analysis and categorisation. According to our findings, justice is an important idea to health care personnel at the studied hospitals. Two main notions of just health care were found. The main (...) idea was the notion of “equal treatment according to need”, the basic idea being that differences in treatment should be justified by differences in needs. The competing idea that merit should affect the treatment received is occasionally encountered, the idea here being that patients, by acting irresponsibly, may no longer deserve to be treated strictly according to needs. In practice, priorities are made on grounds that only partly comply with the basic idea of justice in health care, as it is understood by staff at the studied hospitals. Exceptions are made due to regional differences, considerations of cost-effectiveness, economic incentives, tradition, the daily patient flow, research, private alternatives, patient influence and favouritism of health care personnel. (shrink)

This paper discusses the predicament of Oscar Pistorius. He is a Paralympic gold medallist who wishes to participate in the Olympics in Beijing in 2008. Following a brief introductory section, the paper discusses the arguments that could be, and have been, deployed against his participation in the Olympics, should he make the qualifying time for his chosen event (400m). The next section discusses a more hypothetical argument based upon a specific understanding of the fair opportunity rule. According to this, there (...) may be a case for allowing Pistorius to compete even if he should fail to make the official qualifying time. The final part of the paper reviews the situation at the time of writing and offers some assessment of the strategy of the IAAF in responding to it. It is argued below that the proper focus for assessment of Pistorius's eligibility to compete should not be on whether his blades lead to his having an unfair advantage over his competitors, but instead should focus on whether what he does counts as running. (shrink)

By comparing models of market-based allocation with state-controlled national health care systems, it will be suggested that the way in which different communicaties deal with the allocation of health care is central to their expression of what might be called a moral self-understanding. That is to say that the provision of health care may be expected to be a focus of communal debate, not simply about morally acceptable and unacceptable actions, but also about the community’s understanding of what it is (...) that makes for a worthwhile and morally defensible human life. This moral self-understanding is seen to be entwined with the different concepts of ‘health’ that are implicit in different systems of allocation. In conclusion, it will be suggested that decisions concerning health care allocation must be made in response to a continuing, public and open debate about that health and health care mean to a particular community. (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)

Costs at the end of life disproportionately contribute to health care costs in the United States. Addressing these costs will therefore be an important component in making the U.S. health care system more financially sustainable. In this paper, we explore the moral justifications for having discussions of end-of-life costs in the doctor-patient encounter as part of an effort to control costs. As health care costs are partly shared through pooled resources, such as insurance and taxation, and partly borne by individuals (...) through out-of-pocket expenses, we separate our defense for, and approach to, discussing both pooled and individual aspects of cost. We argue that there needs to be a shift away from formulating the options as a dichotomous choice of paying attention to end-of-life costs versus ignoring such costs. The question should be how personal costs will be managed and how societal expenditures should be allocated. These are issues that we believe patients care about and need to have addressed in a manner with which they are comfortable. Conversations about how money will be spent at the end of life should begin before the end is near. We propose discussing costs from the onset of chronic illness and incorporating financial issues in advance care planning. Through these approaches one can avoid abruptly and insensitively introducing financial issues at the very conclusion of a person's life when one would prefer to address the painful and important issues of spiritual and existential loss that are appropriately the focus when a person is dying. (shrink)

The cost of health care at the end of life accounts for a high proportion of total health care costs in the United States. The percentage of Medicare payments attributable to patients in their last year of life was 28.3% in 1978 and has remained substantially the same at 25.1% in 2006. This indicates how little progress has been made in containing these costs, though doing so will be important to promote a financially sustainable health care system. These expenditures also (...) highlight the prospect that efforts to reduce health care costs overall are likely to disproportionately affect the care patients receive at the end of life. (shrink)

This paper addresses two ways in which scarcity in health care turns up and three ways in which this dual condition of scarcity can be approached. The first approach is the economic approach, which focuses on the causes of cost-increase in health care and on developing various mechanisms of rationing and priority-setting in health care. The second approach is the justice approach, which interprets scarcity as one of the Humean ‹Circumstances of Justice.’ Whereas these approaches interpret scarcity as a given (...) fact, the third approach casts doubt on this interpretation. Rather, it interprets scarcity as a social, anthropological, and technologically induced construction of Modernity. This paper supports the theories of Hans Achterhuis, Ivan Illich, and Nicholas Xenos but also further elaborates their views with regard to health care by offering an approach to scarcity that interprets it as an economic translation of finitude. I argue that this approach, which entails a contemporary revaluation of the ancient Socratic attitude on human life and finitude, will be better able to deal with the pressing contemporary issues of setting limits on health care because it mitigates contemporary health care’s tendency toward infinity in meeting – and creating – health care needs. (shrink)

The ArgumentSome have claimed that negative genetic interventions are morally permissible while positive ones are not, but the distinction cannot be used to draw this moral boundary. Underlying the negative/positive distinction is a distinction between treatment and enhancement. The treatment/enhancement distinction at best provides an imperfect guide to which health care services we are obliged to provide and which we are not. It offers only some “warning flags” to help us think about what is permissible or not.

A moral right to health or health care is a special instance of a right to fair equality of opportunity. Nation-states generally have the capabilities to specify the entitlements of such a right and to raise the resources needed to satisfy those entitlements. Can these functions be replicated globally, as a global right to health or health care requires? The suggestion that “better global governance” is needed if such a global right is to be claimed requires that these two central (...) capabilities be present. It is unlikely that nation-states would concede these two functions to a form of global governance, for doing so would seriously compromise the authority that is generally included in sovereignty. This claim is a specification of what is often recognized as the “sovereignty problem.” The argument of this paper is not an “impossibility” claim, but a best guess about whether the necessary conditions for better global governance that supports a global right to health or health care can be achieved. (shrink)

Using interviews with activists and Lisa Sowle Cahill's concept of participatory discourse, this article examines how the Greater Boston Interfaith Organization (GBIO) built solidarity for the 2006 Massachusetts health care reform law. The analysis explores the morally formative connections between GBIO's activist strategies and its public liturgy for reform. The solidarity generated through this interfaith coalition's activities and religious arguments contrasts with two standard types of policy discourse, economics and liberalism. Arguments for health care reform based on economic efficiency or (...) positive rights are hampered by the lack of solidarity in U.S. political culture. GBIO's congregation-based organizing offers a performative model of public argumentation for religious groups committed to achieving affordable, quality health care for all Americans. (shrink)

Health communication is increasingly being held to higher moral standards. No longer do noble goals outweigh ethical concerns. This content analysis examines ethical frames and primes in health public service announcements so we may begin to address the most prevalent of the problematic ones and find more ethical alternatives. In this study, 80% of the PSAs conveyed messages that individuals were to blame. Negative emotion, such as fear, was the second most frequent frame. Stereotypes of women were the primes most (...) prevalent in the visuals, and visual and verbal messages were vastly different for some of these primes. The ethical implications of each are addressed. (shrink)

The American Journal of Bioethics, Volume 11, Issue 7, Page 15-16, July 2011.

Some are born to sweet delight,Some are born to endless night.William Blake - Auguries of InnocenceIt goes without saying that severe poverty is a human tragedy. The problem of poverty stemming from inequality has however only recently become one of the most fundamental questions in international ethics. The publication in 1972 of Peter Singer's important article, “Famine, Affluence and Morality” certainly marks an important date in the literature. Even those who don't agree with Singer's utilitarian approach will recognize that he (...) was among the first to articulate the problem of poverty on an international scale in philosophical terms. Since then, a greater number of philosophers have examined the problem of world poverty. Some of their work has been extremely influential. (shrink)

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

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)

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)

Due to the significant and often careless human impact on the natural environment, there are serious problems facing the people of today and of future generations. To date, ethical, aesthetic, religious, and economic arguments for the conservation and protection of the natural environment have made relatively little headway. Another approach, one capable of garnering attention and motivating action, would be welcome. There is another approach, one that I will call a rights approach. Speaking generally, this approach is an attempt to (...) address environmental issues via the language and theory of legal and moral rights. Ultimately, it is our duties to our fellow humans that explain why we have duties regarding the natural environment. There are three main contenders among theories that can be called rights approaches to environmental issues. The first identifies the (alleged) human right to a healthful environment as the source of our obligations to conserve and protect nature. The second approach has it that our duties to nature arise from the rights of the constituents of nature themselves, its flora and fauna. The third approach to addressing environmental problems via rights is, I argue, the best path to environmental conservation and protection. This approach—which grounds duties toward nature on the human right to health—has the benefits of being a straightforward, uncontroversial, and simple approach to issues and problems that desperately need to be resolved. (shrink)

One way of evaluating health is in terms of its impact on well-being. It has been shown, however, that evaluating health this way runs into difficulties, since health and other aspects of well-being are not separable. At the same time, the practical implications of the inseparability problem remain unclear. This paper assesses these implications by considering the relations between theories, components, and indicators of well-being.

Although the impact of market reforms in Swedish health care stands out as not very far-reaching in an international comparison, it represents a route away from the features and basic values normally associated with the Swedish or Scandinavian model. Summarizing the development over the last decades, we may identify signs of sustainability as well as change. Popular support for public provision and a robust institutional structure make far-reaching alterations of existing structures less feasible, although most visible changes this far—incremental though (...) they may be—represent a change in which the normative foundations of the Swedish model are challenged. (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)

International research, sponsored by for-profit companies, is regularly criticised as unethical on the grounds that it exploits research subjects in developing countries. Many commentators agree that exploitation occurs when the benefits of cooperative activity are unfairly distributed between the parties. To determine whether international research is exploitative we therefore need an account of fair distribution. Procedural accounts of fair bargaining have been popular solutions to this problem, but I argue that they are insufficient to protect against exploitation. I argue instead (...) that a maximin principle of fair distribution provides a more compelling normative account of fairness in relationships characterised by extreme vulnerability and inequality of bargaining potential between the parties. A global tax on international research would provide a mechanism for implementing the maximin account of fair benefits. This model has the capacity to ensure fair benefits and thereby prevent exploitation in international research. (shrink)

Frances Kamm's characteristically subtle paper in response to Michael Sandel is an intriguing intervention in the long-standing and increasingly frustrating debate over the morality of enhancement...

The history of the documentation of health inequality is long. The way in which health inequality has customarily been documented is by comparing differences in the average health across groups, for example, by sex or gender, income, education, occupation, or geographic region. In the controversial World Health Report 2000, researchers at the World Health Organization criticized this traditional practice and proposed to measure health inequality across individuals irrespective of individuals’ group affiliation. They defended its proposal on the moral grounds without (...) clear explanation. In this paper I ask: is health inequality across individuals of moral concern, and, if so, why? Clarification of these questions is crucial for meaningful interpretation of health inequality measured across individuals. Only if there was something morally problematic in health inequality across individuals, its reduction would be good news. Specifically, in this paper I provide three arguments for the moral significance of health inequality across individuals: (a) health is special, (b) health equity plays an important and unique role in the general pursuit of justice, and (c) health inequality is an indicator of general injustice in society. I then discuss three key questions to examine the validity of these arguments: (i) how special is health?, (ii) how good is health as an indicator?, and (iii) what do we mean by injustice? I conclude that health inequality across individuals is of moral interest with the arguments (b) and (c). (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)

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)

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)

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)

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)

Traditional Chinese culture, Confucianism, in particular, has a non-individualist conception of what it is to be human. It conceives of people fundamentally as members of social groups—specifically, the family, the clan, the political community and the state—not as atomic individuals as perceived in modern society. The communist ideology since the middle of the last century also emphasizes the significance of ‘the common good’ of the state which describes a specific ‘good’ that is shared and beneficial for all (or most) members (...) of a given community. Nevertheless, marketization and decentralization in China today have significantly challenged the notion of a state-oriented community that directly impacts China's healthcare system, beginning with the dismantling of the rural collectives and state-owned enterprises as part of the reform and opening process. This article will address healthcare challenges in China today, examining the conceptual/ethical issues raised by public healthcare, and contending that public health concerns should go beyond the dichotomy between individualism and collectivism. The article will argue that the family-oriented model of Confucianism offers an alternative way to look at what constitute a community and common goods. The Confucian approach to ethics is relevant to healthcare today. For example, it will be much easier to find a shared idea of common good in terms of complicated issues like healthcare; it would make sense to give a larger role to families via family savings accounts, and not have everything determined by the government. (shrink)

Patients and physicians often perceive the current health care system to be unfair, in part because of the ways in which coverage decisions appear to be made. To address this problem the Ethical Force Program, a collaborative effort to create quality improvement tools for ethics in health care, has developed five content areas specifying ethical criteria for fair health care benefits design and administration. Each content area includes concrete recommendations and measurable expectations for performance improvement, which can be used by (...) those organizations involved in the design and administration of health benefits packages, such as purchasers, health plans, benefits consultants, and practitioner groups. (shrink)

The unfairness of health inequalities depends on the more fundamental question of the relationship between justice in health and distributive justice more generally. In this article, I discuss some constraints on how health should be incorporated in a theory of justice and their implications for when health inequalities can be considered to be unfair. I argue against adopting separate distributive principles for health, and in favour of conceiving justice in health as interrelated with, and contingent on, justice in the distribution (...) of other important social goods and resources, in particular income. Accordingly, health inequalities are unfair when they are the result of an unfair distribution of resources. (shrink)

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.

There is an underappreciated disconnect between the ultimate values that lie at the heart of contemporary theories of distributive justice, and the practice of state institutions. State institutions deliver “intermediate goods” – goods such as health-care, education, housing, transportation, and the like – that are instrumental to a society being distributively just, but that do not in an of themselves constitute criteria of justice. Researchers who have emphasized the “social determinants of health” provide an insight that, when generalized, point us (...) in a direction that theorists of distributive justice should follow, that of attending not just to the instrinsic value of intermediate goods, but also to their causal contributions to realizing the values that theories of distributive justice make central. “Platforms”, which represent principle-driven attempts at designing compossible policies that attend both to the causal and to the intrinsic value of intermediate goods, should be given more importance within theories of distributive justice if such theories are to be policy-relevant, for they connect the ultimate values of these theories to the practices of state institutions. (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)

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)

Most work addressing clinical workers' professional responsibilities concerns the norms of conduct within established professional–patient relationships, but such responsibilities may extend beyond the clinical context. We explore health workers' professional responsibilities in such “informal” encounters through the example of a doctor witnessing the misdiagnosis and mistreatment of a serious long-term condition in a television documentary, arguing that neither internalist approaches to professional responsibility nor externalist ones provide sufficiently clear guidance in such situations. We propose that a mix of both approaches, (...) emphasizing the noncomplacency and practical wisdom of virtue ethics, but grounding the normative authority of virtue in an external source, is able to engage with the health worker's responsibilities in such situations to the individual, the health care system, and the population at large. (shrink)

Limited health literacy is a pervasive and independent risk factor for poor health outcomes. Despite decades of reports exhibiting that the healthcare system is overly complex, unneeded complexity remains commonplace and endangers the lives of patients, especially those with limited health literacy. In this article, we define health literacy and describe the empirical evidence associating health literacy and poor health outcomes. We recast the issue of poor health literacy from within the ethical perspective of the least well-off and argue that (...) poor health outcomes deriving from limited health literacy ought to be understood as a fundamental injustice of the healthcare system. We offer three proposals that attempt to rectify this injustice, including: universal precautions that presume limited health literacy for all healthcare users; expanded use of technology supported communication; and clinical incentives that account for limited health literacy. (shrink)