In Wrong Medicine, Lawrence J. Schneiderman, M.D., and Nancy S. Jecker, Ph.D., address issues that have occupied the media and the courts since the time of Karen Ann Quinlan. The authors examine the ethics of cases in which medical treatment is offered--or mandated--even if a patient lacks the capacity to appreciate its benefit or if the treatment will still leave a patient totally dependent on intensive medical care. In exploring these timely issues Schneiderman and Jecker reexamine the doctor-patient relationship and (...) call for a restoration of common sense and reality to what we expect from medicine. They discuss economic, historical, and demographic factors that affect medical care and offer clear definitions of what constitutes futile medical treatment. And they address such topics as the limits on unwanted treatment, the shift from the "Age of Physician Paternalism" to the "Age of Patient Autonomy," health care rationing, and the adoption of new ethical standards. (shrink)

In this paper I argue that a narrow view of justice dominates the bioethics literature. I urge a broader view. As bioethicists, we often conceive of justice using a medical model. This model focuses attention at a particular point in time, namely, when someone who is already sick seeks access to scarce or expensive services. A medical model asks how we can fairly distribute those services. The broader view I endorse requires looking upstream, and asking how disease and suffering came (...) about. In contrast to a medical model, a social model of justice considers how social determinants affect the health of a population. For example, social factors such as access to clean drinking water, education, safe workplaces, and police protection, profoundly affect risk for disease and early death. I examine one important social determinant of health, health care coverage, to show the limits of a medical model and the merits of a broader view. (shrink)

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)

People often have a strong intuitive sense that we ought to rescue those in serious need, even in cases where we could produce better outcomes by acting in other ways. It has become common in such cases to refer to this as the Rule of Rescue. Within the medical field this rule has predominantly been discussed in relation to decisions about whether to fund particular treatments. Whilst in this setting the arguments in favour of the Rule of Rescue have generally (...) been found to be unconvincing, there are some reasons for thinking that it may have more of a role to play at the clinical level. In this article we examine three lines that such reasoning might take. In each case we argue that the reasons given do not support the adoption of a Rule of Rescue in clinical practice. (shrink)

Should the nation provide expensive care and scarce organs to convicted felons? We distinguish between two fields of justice: Medical Justice and Societal Justice. Although there is general acceptance within the medical profession that physicians may distribute limited treatments based solely on potential medical benefits without regard to nonmedical factors, that does not mean that society cannot impose limits based on societal factors. If a society considers the convicted felon to be a full member, then that person would be entitled (...) to at least a decent minimum level of care — which might include access to scarce life-saving organs. However, if criminals forfeit their entitlement to the same level of medical care afforded to all members of society, they still would be entitled to a kind of rudimentary decent minimum granted to all persons on simple humanitarian grounds. Almost certainly this entitlement would not include access to organ transplants. (shrink)

Bioethicists invoke a duty to rescue in a wide range of cases. Indeed, arguably, there exists an entire medical paradigm whereby vast numbers of medical encounters are treated as rescue cases. The intuitive power of the rescue paradigm is considerable, but much of this power stems from the problematic way that rescue cases are conceptualized—namely, as random, unanticipated, unavoidable, interpersonal events for which context is irrelevant and beneficence is the paramount value. In this article, I critique the basic assumptions of (...) the rescue paradigm, reframe the ethical landscape in which rescue obligations are understood, and defend the necessity and value of a wider social and institutional view. Along the way, I move back and forth between ethical theory and a concrete case where the duty to rescue has been problematically applied: the purported duty to regularly return incidental findings and individual research results in genomic and genetic research. (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)

Universal access to health care is still a dream rather than a reality in the United States. This is partly because a rule of rescue, by impelling us to help people in need, urges us to ignore the limits of our health care policies wherever those limits would adversely affect a given individual. As the rule of rescue undermines whatever limits we set on health care entitlements, it can thwart the cost containment so essential to expanding access. Rather than accept (...) unlimited expense, we have thus far declined to universalize health care. The situation is exacerbated by an economic insulation shielding patients and physicians from the costs of care, prompting both to regard health care as free, an unlimited right. To reverse this costly entitlement mentality and place reasonable limits on rescue, patients must exercise greater personal responsibility for the costs of their care by directly experiencing some of the economic consequences of their health care decisions. Several mechanisms are available to accomplish this goal without posing economic barriers to needed care or penalizing people for becoming ill. Keywords: Clinton health plan, rationing, rule of rescue CiteULike Connotea Del.icio.us What's this? (shrink)