This paper is in three parts. In Part One we briefly explain that an unsophisticated form of utilitarianism—economic rationalism (ER)—has become dominant in many health systems. Its proponents argue that one of ER’s most important effects is to increase consumer choice. However, evidence from New Zealand does not support this claim. Furthermore, the logic of ER requires the construction of systems which tend to restrict individual participation.In Part Two we argue that although some have advocated an ‘ethic of care’ in (...) an attempt to counteract ER’s utilitarianism, two decades of campaigning have had little influence on health policy. ER’s pro-care adversaries have failed to make an impact because they have not developed a taxonomy of care—they have not established a language compatible with, or as powerful as, ER’s.In Part Three, in an attempt to raise the conceptual and practical status of caring in contemporary health systems, we distinguish four different forms of care. In opposition to those who believe the ‘ethic of care’ can adequately direct health care practice, we demonstrate that care is a secondary notion. We show that in order for a carer to decide which form of care to adopt in different situations she requires a more powerful idea. We contend further that health care ought to be governed by a theory of health, and suggest that ‘the foundations theory of health’ should be adopted by planners searching for a more humane alternative to ER. We conclude that ER’s dominance can and must be challenged. However, only those arguments which offer detailed theoretical analyses of health care, as well as meticulously derived practical policies, have any chance of success. (shrink)

This paper responds to Dr Cassell's request for a fuller explanation of my argument in the paper, Against medical ethics: a philosopher's view. A distinction is made between two accounts of ethics in general, and the philosophical basis of health work ethics is briefly stated. The implications of applying this understanding of ethics to medical education are discussed.

Many leading health economists hold misconceived ideas about central components of their work. In particular, they assume that their methods are in principle valueneutral. This belief is demonstrably false. Health economic investigations incorporate mainly unexpressed theories of health. Unless this fact is recognised health economics will shortly reach a conceptual and practical dead end. The way to avoid this dead end is to express implicit theories of health, and explicitly to base philosophically and economically justifiable policy proposals on them.

A number of recent publications by the philosopher David Seedhouse are discussed. Although medicine is an eminently ethical enterprise, the technical and ethical aspects of health care practices can be distinguished, therefore justifying the existence of medical ethics and its teaching as a specific part of every medical curriculum. The goal of teaching medical ethics is to make health care practitioners aware of the essential ethical aspects of their work. Furthermore, the contention that rational bioethics is a fruitless enterprise because (...) it analyses non-rational social events seems neither theoretically tenable nor to be borne out by actual practice. Medical ethics in particular and bioethics in general, constitute a field of expertise that must make itself understandable and convincing to relevant audiences in health care. (shrink)

In this paper it is argued that bioethics has tended to emphasise: ‘high tech’ areas of medicine at the expense of ‘low tech’ areas such as psychiatry; problems arising in treatment at the expense of those associated with diagnosis; questions of fact at the expense of questions of value; and applied ethics at the expense of philosophical theory. The common factor linking these four ‘bioethical blind spots’ is a failute to recognise the full extent to which medicine is an ethical (...) as well as scientific discipline. Once this is acknowledged it leads to a full-field bioethics in which the different areas are mutually complementary. In particular, it paves the way for a fruitful two-way exchange between the more abstract aspects of philosophical theory and the contingencies of day-to-day clinical work. The arguments of the paper are illustrated with recent work on the abuse of psychiatry. (shrink)