Healthcare (including public health) is special because it protects normal functioning, which in turn protects the range of opportunities open to individuals. I extend this account in two ways. First, since the distribution of goods other than healthcare affect population health and its distribution, I claim that Rawls's principles of justice describe a fair distribution of the social determinants of health, giving a partial account of when health inequalities are unjust. Second, I supplement a principled account of justice for health (...) and healthcare with an account of fair process for setting limits or rationing care. This account is provided by three conditions that comprise "accountability for reasonableness.". (shrink)

I introduce a distinction between health need and medical need, and raise several questions about their interaction. Health needs are needs that relate directly to our health condition. Medical needs are needs which bear some relation to medical institutions or processes. I suggest that the question of whether medical insurance or public care should cover medical needs, health needs, or only needs which fit both categories is a political question that cannot be resolved definitionally. I also argue against an overly (...) strict definition of medical need on the grounds that this presupposes, wrongly, that medical intervention should always be a last resort. (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)

In this paper, we argue that there are reasons to believe that an implicit bias for normalcy influences what are considered medically necessary treatments in psychiatry. First, we outline two prima facie reasons to suspect that this is the case. A bias for ‘the normal’ is already documented in disability studies; it is reasonable to suspect that it affects psychiatry too, since psychiatric patients, like disabled people, are often perceived as ‘weird’ by others. Secondly, psychiatry's explicitly endorsed values of well-being (...) and function are hard to measure directly, which is why we see simpler box-ticking conceptions of recovery used in large research studies. This need not be problematic, but might lead to researchers and clinicians focusing too much on treatments that promote easy-to-measure proxies for recovery, instead of what actually matters to psychiatric patients themselves. Next, we provide examples of treatments and treatment decisions within two areas – self-injury and psychosis – which are hard to explain unless we assume that an implicit and harmful normalcy bias is at work. We conclude with some suggestions for clinicians and future research. (shrink)

The main objection to genetic enhancement is that it will create a “genetic apartheid,” deepening existing inequalities. This paper offers considerations that can weaken the inequality argument against genetic enhancement. First, I question the dichotomy of treatment versus enhancement since the differences between the two are unclear. Second, I argue that human enhancement is part of human nature and that there is no sound reason to accept it in other domains while rejecting it in genetics. The paper also demonstrates that (...) inequality is present in every dimension of society, that “God-given” genetics is profoundly unequal, and that genetic enhancement can operate as a mechanism by which a new genetic equality can be achieved. However, the paper underlines that genetic equality is not, per se, a value to which we ought to aspire if it leads us to a uniform community of downsized human beings. Genetic equality is only valuable if it enhances humankind in general. (shrink)

The availability of a range of new psychotropic agents raises the possibility that these will be used for enhancement purposes (smart pills, happy pills, and pep pills). The enhancement debate soon raises questions in philosophy of medicine and psychiatry (eg, what is a disorder?), and this debate in turn raises fundament questions in philosophy of language, science, and ethics. In this paper, a naturalistic conceptual framework is proposed for addressing these issues. This framework begins by contrasting classical and critical concepts (...) of categories, and then puts forward an integrative position that is based on cognitive-affective research. This position can in turn be used to consider the debate between pharmacological Calvinism (which may adopt a moral metaphor of disorder) and psychotropic utopianism (which may emphasize a medical metaphor of disorder). I argue that psychiatric treatment of serious psychiatric disorders is justified, and that psychotropics are an acceptable kind of intervention. The use of psychotropics for sub-threshold phenomena requires a judicious weighing of the relevant facts (which are often sparse) and values. (shrink)

There are numerous ways people can improve their cognitive capacities: good nutrition and regular exercise can produce long-term improvements across many cognitive domains, whilst commonplace stimulants such as coffee temporarily boost levels of alertness and concentration. Effects like these have been well-documented in the medical literature and they raise few ethical issues. More recently, however, clinical research has shown that the off-label use of some pharmaceuticals can, under certain conditions, have modest cognition-improving effects. Substances such as methylphenidate and modafinil can (...) improve capacities such as working memory and concentration in some healthy individuals. Unlike their more mundane predecessors, these methods of “cognitive enhancement” are thought to raise a multitude of ethical issues. This paper presents the six principal ethical issues raised in relation to pharmacological cognitive enhancers —issues such as whether: the medical safety-profile of PCEs justifies restricting or permitting their elective or required use; the enhanced mind can be an “authentic” mind; individuals might be coerced into using PCEs;, there is a meaningful distinction to be made between the treatment vs. enhancement effect of the same PCE; unequal access to PCEs would have implications for distributive justice; and PCE use constitutes cheating in competitive contexts. In reviewing the six principal issues, the paper discusses how neuroscientific research might help advance the ethical debate. In particular, the paper presents new arguments about the contribution neuroscience could make to debates about justice, fairness, and cheating, ultimately concluding that neuroscientific research into “personalized enhancement” will be essential if policy is to be truly informed and ethical. We propose an “ethical agenda” for neuroscientific research into PCEs. (shrink)

The use of Ritalin and other stimulant drug treatments for attention-deficit hyperactivity disorder (ADHD) raises distinctive moral dilemmas for parents; these moral dilemmas have not been adequately addressed in the bioethics literature. This paper draws upon data from a qualitative empirical study to investigate parents' use of the moral ideal of authenticity as part of their narrative justifications for dosing decisions and actions. I show that therapeutic decisions and actions are embedded in valued cultural ideals about masculinity, self-actualization and success, (...) as well as in moral conceptions of authenticity and personal freedom. I argue that this investigation of parents' moral justifications and dosing dilemmas raises questions about the validity of authenticity as a transcendent moral principle. Moreover, this study demonstrates that in order to be relevant, bioethical analysis of neurocognitive enhancement must engage with ground-up studies of moral principles and decision-making in context. (shrink)

The concept of medical necessity is often used to explain or justify certain decisions—for example, which treatments should be allowed under certain conditions—as though it had an obvious, agreed-upon meaning as well as an inherent normative force. In introducing this special issue of Clinical Ethics on medical necessity, we argue that the term, as used in various discourses, generally lacks a definition that is clear, non-circular, conceptually plausible, and fit for purpose. We propose that future work on this concept should (...) address three main questions: what medical necessity is (i.e., what makes something medically necessary, as opposed to something else); what the concept does (what ‘work’ is it doing when invoked in different settings); and what should follow, normatively, from the fact that something is indeed medically necessary (on some plausible conception). (shrink)

There is little debate regarding the acceptability of providing medical care to restore physical or mental health that has deteriorated below what is considered typical due to disease or disorder (i.e., providing “treatment”—for example, administering psychostimulant medication to sustain attention in the case of attention deficit disorder). When asked whether a healthy individual may undergo the same intervention for the purpose of enhancing their capacities (i.e., “enhancement”—for example, use of a psychostimulant as a “study drug”), people often express greater hesitation. (...) Building on prior research in moral philosophy and cognitive science, in this work, we ask why people draw a moral distinction between treatment and enhancement. In two experiments, we provide evidence that the accessibility of health-related interventions determines their perceived descriptive or statistical normality (Experiment 1), and that gains in descriptive normality for such interventions weaken the moral distinction between treatment and enhancement (Experiment 2). In short, our findings suggest that the tendency to draw a moral distinction between treatment and enhancement is driven, in part, by assumptions about descriptive abnormality; and raise the possibility that normalizing novel biomedical interventions by promoting access could undermine people’s selective opposition toward enhancement, rendering it morally comparable to treatment. (shrink)

Die Fortschritte in der Psychopharmakologie führen zu einem immer breiteren Angebot an Substanzen zur Verbesserung der Stimmung, des Gedächtnisses oder der exekutiven Funktionen. Dieses Angebot trifft auf die Wünsche und Bedürfnisse vieler Menschen, ihre mentalen Leistungen und Zustände zu verbessern. Wie sollte die Medizin mit diesen Wünschen umgehen? An welchen Kriterien sollte sich insbesondere der ärztliche Entscheidungsprozess orientieren? Im Folgenden soll gezeigt werden, dass sich aus einer „Treatment-enhancement-Unterscheidung“, einem Krankheits- oder Normalitätsbegriff oder einem bestimmten Medizinkonzept keine zielführenden normativen Kriterien für (...) diesen Entscheidungsprozess ableiten lassen. Demgegenüber wird ein Entscheidungsmodell entwickelt, das auf traditionellen Kriterien ärztlichen Handelns beruht: dem Kriterium des Wohlergehens, des Nichtschadens und der Autonomie. Mit diesem Modell soll zugleich ein neues Konzept einer „wunscherfüllenden Medizin“ vorgeschlagen werden: eine subjektive Medizin mit ärztlichem Empfehlungs- und Vetovorbehalt. (shrink)

The current dominant paradigm of mental disorder is that psychopathology is a deviation from normal physiological functioning of the brain. This paradigm is closely allied to the identity theory of mind in philosophy, which holds that mental phenomena are identical with the physical state of the brain. The assumptions of the biological model have policy implications, regardless of the utility or ‘truth’ of the paradigm, which should be made explicit for the assessment of ethics in mental health policy formulation. The (...) nature of mental phenomena has been debated throughout history, without consensus. Several critiques of the biological model are offered to encourage enquiring scepticism. The policy implications discussed are political conservatism, broadened rationales for forced treatment, utility in managed care, and the use of medical necessity criteria to allocate treatment. (shrink)

In recent years, neuroscience has been a particularly prolific discipline stimulating many innovative treatment approaches in medicine. However, when it comes to the brain, new techniques of intervention do not always meet with a positive public response, in spite of promising therapeutic benefits. The reason for this caution clearly is the brain’s special importance as “organ of the mind”. As such it is widely held to be the origin of mankind’s unique position among living beings. Likewise, on the level of (...) the individual human being, the brain is considered the material substrate of those traits that in combination render each person unique. In view of this preeminent significance of the brain, it is understandable that, in general, interventions into the brain are considered a delicate issue and that new techniques of intervention are scrutinised with particular care. However, in doing so it is important not to go to the opposite extreme and shy away from promising new therapeutic approaches for debilitating disorders of the brain. With respect to the new techniques of brain intervention a broad interdisciplinary perspective is required to discern irrational fear from justified concern. Hence, the Europäische Akademie established a project group consisting, on the one hand, of experts from different fields of medicine who have got first-hand experience of applying the techniques at issue and, on the other hand, of philosophers and a legal expert. The task of this team was to review the state of the art with respect to each single technique of intervening in the brain, to indicate future developments, and to address the ethical and legal issues common to all of them. The project’s outcome is the book at hand. (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 examines the concept of medical necessity as it relates to mental health care rationing, arguing that the normal functioning model of medical necessity is insufficient because it fails to cohere with an important aim and function of mental health care, which is to provide support for individuals in abusive or otherwise difficult personal relationships.

Die Fortschritte in der Psychopharmakologie führen zu einem immer breiteren Angebot an Substanzen zur Verbesserung der Stimmung, des Gedächtnisses oder der exekutiven Funktionen. Dieses Angebot trifft auf die Wünsche und Bedürfnisse vieler Menschen, ihre mentalen Leistungen und Zustände zu verbessern. Wie sollte die Medizin mit diesen Wünschen umgehen? An welchen Kriterien sollte sich insbesondere der ärztliche Entscheidungsprozess orientieren? Im Folgenden soll gezeigt werden, dass sich aus einer „Treatment-enhancement-Unterscheidung“, einem Krankheits- oder Normalitätsbegriff oder einem bestimmten Medizinkonzept keine zielführenden normativen Kriterien für (...) diesen Entscheidungsprozess ableiten lassen. Demgegenüber wird ein Entscheidungsmodell entwickelt, das auf traditionellen Kriterien ärztlichen Handelns beruht: dem Kriterium des Wohlergehens, des Nichtschadens und der Autonomie. Mit diesem Modell soll zugleich ein neues Konzept einer „wunscherfüllenden Medizin“ vorgeschlagen werden: eine subjektive Medizin mit ärztlichem Empfehlungs- und Vetovorbehalt. (shrink)

Developments in Non-Invasive Prenatal Testing (NIPT) and cell-free fetal DNA analysis raise the possibility that antenatal services may soon be able to support couples in non-invasively testing for, and diagnosing, an unprecedented range of genetic disorders and traits coded within their unborn child’s genome. Inevitably, this has prompted debate within the bioethics literature about what screening options should be offered to couples for the purpose of reproductive choice. In relation to this problem, the European Society of Human Genetics (ESHG) and (...) American Society of Human Genetics (ASHG) tentatively recommend that any expansion of this type of screening, as facilitated by NIPT, should be limited to serious congenital and childhood disorders. In support of this recommendation, the ESHG and ASHG cite considerations of distribution justice. Notably, however, an account of justice in the organization and provision of this type of screening which might substantiate this recommendation has yet to be developed. This paper attempts to redress this oversight through an investigation of Norman Daniels’ theory of Just health: meeting health needs fairly. In line with this aim, the paper examines what special moral importance (for Just health) screening for the purpose of reproductive choice might have where concerning serious congenital and childhood disorders in particular. The paper concludes that screening for reproductive choice where concerning serious congenital and childhood disorders may be important for providing women with fair opportunity to protect their health (by either having or not having an affected child). (shrink)

In this chapter, I propose the mechanism of cognitive enhancement based on studies of cognitive-enhancing drugs and behavioral training. I argue that there are mechanistic differences between cognitive-enhancing drugs and behavioral training due to their different enhancing effects. I also suggest possible mechanisms for cognitive-enhancing drugs and behavioral training and for the synergistic effects of their simultaneous application.

The application of continuous deep sedation in the treatment of intractable suffering at the end of life continues to be tied to a number of concerns that have negated its use in palliative care. Part of the resistance towards use of this treatment option of last resort has been the continued association of CDS with physician-associated suicide and/or euthanasia, which is compounded by a lack clinical guidelines and a failure to cite this treatment under the aegis of a palliative care (...) approach. I argue that reinstituting a palliative care-inspired approach that includes a holistic review of the patient’s situation and the engagement of a multidisciplinary team guided by clearly defined practice requirements that have been lacking amongst many prevailing guidelines will overcome prevailing objections to this practice and allow for the legitimization of this process. (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.

In a 2002 speech, Mark McClellan, a member of the Council of Economic Advisors at the White House, said that "[I]n the president's vision, all Americans should have access to high-quality and affordable healthcare." However, many healthcare researchers believe that a growing number of Americans are underinsured. Because any characterization of underinsurance will refer to the value judgments of people about what counts as "adequate" and "inadequate" healthcare, the goal of characterizing and measuring the underinsured is difficult to achieve. In (...) this article, I examine the various dimensions of underinsurance, and propose a typology incorporating those dimensions. (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)