This review essay examines H. Tristram Engelhardt, Jr.'s The Foundations of Bioethics, a contemporary nonfeminist text in mainstream biomedical ethics. It focuses upon a central concept, Engelhardt's idea of the moral community and argues that the most serious problem in the book is its failure to take account of the political and social structures of moral communities, structures which deeply affect issues in biomedical ethics.

This collection of essays, Global Bioethics: The Collapse of Consensus, deals with the issue of the repeated failure of attempts to derive a universal set of ...

This essay focuses on the challenge European states have imposed on themselves, namely, to provide state-of-the-art health care equally to all and for less than market price. Continued endorsement of that challenge in these states hinges on their character as media democracies: the public is moved by a supposed morally warranted expectation that all should receive adequate health care at no significant personal cost. The structural and economic constraints that hamper such forms of healthcare delivery result in systems that are (...) financially inefficient and fail to provide the quality of treatment patients are led to expect. This essay examines the tension between secular moral claims to social solidarity and the actual limits of accessibility to healthcare services. Its critical focus addresses both the difficulties that result from politicians invoking high moral ideals while framing their decisions around short-term political advantage, and the transformation of the Enlightenment’s secular aspirations into a political ideology that distorts such moral ideals. This essay concludes that the commitments to very particular notions of equality and human dignity, which frame contemporary Europe’s provision of publicly subsidized health care, have given rise to a governance that is morally incoherent and unsustainable. This failure of public health care in Europe can thus be read as one more belated manifestation of the epistemological and moral failure of the Enlightenment’s secularizing project, a failure which should invite contemporary Europeans to honestly face the moral challenge of postmodernity. (shrink)

Libertarian views on rights tend to rule out coercive redistribution for purposes of public health care guarantees, whereas liberal conceptions support coercive funding of potentially unlimited access to medical services in the name of medical needs. Taking the “priority of liberty” seriously as supreme political value, a plausible prudential argument can avoid these extremes by providing systematic reasons for both delivering and limiting publicly financed guarantees. Given impending demographic change and rapid technical progress in medicine, only a two-tier system with (...) explicitly limited public guarantees and optional privately financed health services seems acceptable. (shrink)

This article sets out the moral failure of single-tier basic healthcare. Single-tier basic healthcare has been advocated on the grounds that the provision of healthcare should be divorced from ability to pay and unequal access to basic healthcare is morally intolerable. However, single-tier basic healthcare encounters a host of catastrophic moral failings. Given the fact of human pluralism it is impossible to objectively define “basic” healthcare. Attempts to provide single-tier healthcare therefore become political processes in which interest groups compete for (...) control of scarce resources with the most privileged possessing an inherent advantage. The focus on outputs in arguments for single-tier provision neglects the question of justice between individuals when some people provide resources for others without reciprocal benefits. The principle that only healthcare that can be provided to everyone should be provided at all leads to a leveling-down problem in which advocates of single-tier provision must prefer a situation where some individuals are made worse-off without any individual being made better-off compared to plausible multi-tier alternatives. Contemporary single-tier systems require the exclusion of noncitizens, meaning that their universalism is a myth. In the light of these pathologies, it is judged that multi-tier healthcare is morally required. (shrink)

The state subvention and distribution of health care not only jeopardize the financial sustainability of the state, but also restrict without a conclusive rational basis the freedom of patients to decide how much health care and of what quality is worth what price. The dominant biopolitics of European health care supports a healthcare monopoly in the hands of the state and the medical profession, which health care should be opened to the patient’s authority to deal directly for better basic health (...) care. In a world where it is impossible for all to receive equal access to the best of basic health care, one must critically examine the plausible scope of the authority of the state to limit access to better basic health care. Classical distributive justice affords a basis for re-examining the current European ideology of equality, human dignity, and solidarity that supports healthcare systems with unsustainable egalitarian concerns. (shrink)

Are values and social priorities universal, or do they vary across geography, culture, and time? This question is very relevant to Asia’s emerging economies that are increasingly looking at Western models for answers to their own outmoded health care systems that are in dire need of reform. But is it safe for them to do so without sufficient regard to their own social, political, and philosophical moorings? This article argues that historical and cultural legacies influence prevailing social values with regard (...) to health care financing and resource allocation, and that the Confucian dimension provides a helpful entry point for a deeper understanding of ongoing health care reforms in East Asia – as exemplified by the unique case of Singapore. (shrink)

All over Europe, the provision of healthcare services is widely considered a primary duty of the government. Universal access to medical care can be considered a basic ingredient of the so-called “European social model.” But if universal access to medical care is seldom questioned, European governments—faced with expanding costs caused by an increasing demand driven by an aging population and technology-driven improvements—are contemplating the possibility of “rationing”1 treatments, or the possibility of allowing a greater role for private suppliers. If a (...) “multi-tier” healthcare system has long been anathema to the European leadership, guaranteeing a uniform access to state-of-the-art care seems to be well beyond the means of states suffering from persisting debt crisis. Was the failure of state-controlled “adequate” healthcare totally unpredictable? Far-sighted criticisms had been offered by two eminent thinkers in the classical liberal tradition, Herbert Spencer and Friedrich A. von Hayek . Neither author is usually recognized as a forerunner of contemporary critics of the welfare state, and both investigated the issue of the state financing and providing health services well before or right after the establishment of national health services. With the benefit of hindsight, reading Spencer and Hayek helps us to understand how the crisis of state-supplied healthcare is not rooted in the mere progress of clinical technology, but is rather the logical consequence of the theoretical basis of the model itself. Whereas modern theorists of the welfare state tend to offer theories that are impervious to a critical appraisal of their unintended consequences—insofar as they are framed in a language of “rights”—both Hayek and Spencer understood that human systems are complex, and that unwanted effects of public policy should be taken into account. Although Spencer emphasized the moral hazards accruing from the paternalism involved in governmental provision of health services, Hayek explained how modern healthcare systems differ from real, private insurance designed to offer proper coverage against risks. These authors appreciated that the politicization of healthcare was bound to result in both standardization of care and disregard for the responsibility that comes with personal freedom. These two “diagnoses before the illness” can help us in defining the challenges and the potential solutions that healthcare systems face today. Understanding the fatal conceits inherent in the very architecture of national health services can be the first step toward healing our healthcare systems. (shrink)

Background: Obstructive sleep apnea syndrome (OSAS) is one of the representative sleep disorders believed to be associated with metabolic syndrome. Nasal continuous positive airway pressure (nCPAP) ventilation is the first choice therapy for OSAS, which has been reported to cause an improvement in body fat mass, hepatocellular damage and hypertension. Study Objectives: We evaluated whether the changes in the body weight observed in patients with OSAS may have potential associations with the sleep time during which the patients are under nCPAP. (...) Method: A total of 194 patients (148 obese and 46 non-obese) in whom nCPAP use was present for more than 70% of the nights were enrolled in this study. Using the electronic records of the night use time for CPAP devices, we examined whether the habitual sleep time during nCPAP is associated with changes in body weight. Results: In the non-obese OSAS group, the patients with night time use of nCPAP devices for 6 to 7 hours showed the greatest and the most sustained decrease in body weight. In the obese patients with OSAS, on the other hand, a U-shaped relationship has been demonstrated between a percent weight gain over 9 years and a minimal weight gain in patients with habitual sleep for 5 to 6 hours. Conclusions: These results suggest that changes in body weight in patients with OSAS are associated with habitual sleep time. eww141010dxn. (shrink)