In the context of the end of life, many authors point out how the experience of identity is crucial for the well-being of patients with advanced disease. They define this identity in terms of autonomy, control, or dependence, associating these concepts with the sense of personal dignity. From the perspective of the phenomenology of embodiment, Kay Toombs and other authors have investigated the ways disease can impact on the subjective world of patients and have stressed that a consideration of this (...) personal world can promote understanding and recognition of their experience. Based on the findings of qualitative studies of the perception of dignity and autonomy in patients at the end of life, this analysis assesses concepts such as being-in-the-world in illness, embodiment, lived body versus objective body or the gaze of the other from a Toombsian phenomenological perspective. (shrink)

Book reviewed in this article: The Meaning of Illness. By S. Kay Toombs.

The arguments against managed care can be divided into two general clusters. One cluster concerns the way managed care undermines the ethical ideals of medical professionalism. Since those ideals largely focus on the physician-patient relation, the first cluster comes under the rubric of micro-ethics; namely, the ethics of individual-individual relations. The second cluster of criticisms focuses on macro-ethical issues, primarily on issues of justice and policy. By reviewing these arguments, it becomes clear that managed care does not easily fit within (...) traditional modes of ethical analysis. It poses a radical challenge to current medical and socio-political norms, and even resists the distinction between micro- and macro-ethical domains, a distinction that reflects the private/public distinction. Managed care organizations call for a third way, an inter-ethic for middle level organizations. The essays in this Journal provide a first step in this radical reassessment, laying the foundation for an organizational ethic that is responsive to the realities and promise of managed care. (shrink)

In this paper, changes in identity and selfhood experienced through organ transplantation are analyzed from a phenomenological point of view. The chief examples are heart and face transplants. Similarities and differences between the examples are fleshed out by way of identifying three layers of selfhood in which the procedures have effects: embodied selfhood, self-reflection, and social-narrative identity. Organ transplantation is tied to processes of alienation in the three layers of selfhood, first and foremost a bodily alienation experienced through illness or (...) injury and in going through and recovering from the operation. However, in cases in which the organ in question is taken to harbor the identity of another person, because of its symbolic qualities (the heart) or its expressive qualities (the face), the alienation process may also involve the otherness of another person making itself, at least imaginatively, known. (shrink)

This article concerns the morality of establishing regulated kidney markets in an effort to reduce the chronic shortage of kidneys for transplant. The article tries to rebut the view, recently defended by James Taylor, that if we hold autonomy to be intrinsically valuable, then we should be in favor of such markets. The article then argues that, under current conditions, the buying and selling of organs in regulated markets would sometimes violate two Kantian principles that are seen as moral constraints. (...) One principle forbids expressing disrespect for the dignity of humanity; the other forbids treating others merely as means. In light of the moral danger posed by regulated markets, the article advocates an alternative way of diminishing the current organ shortage, namely opt-out systems of cadaveric organ donation. (shrink)

Recent discussions of genetic enhancement have argued that unregulated access to genetic enhancement technology will have a mainly negative impact on equality, a development that an egalitarian approach to distributive justice should be concerned with and seek to address. I argue that the extent to which egalitarians should be concerned about unequal access to genetic enhancement therapies has been overplayed. Many of the genetic differences that exist between people, including those that arise from differential access to genetic enhancement technology, are (...) simply irrelevant to egalitarian concerns. I also argue that most commentators have failed to appreciate that an egalitarian-inspired program of equal access to genetic enhancement technology may not be altogether favourable for the genetically disadvantaged in any case. The true implications of egalitarian justice in the genetic future have not been adequately explored. (shrink)

Several commentators have tried to ground legal prohibitions of kidney sales in some form of Kant’s moral arguments against such sales. This paper reconsiders this approach to justifying laws and policies in light of Kant’s approach to law in his political philosophy. The author argues that Kant’s political philosophy requires that kidney sales be legally permitted, although contracts for such sales must remain unenforceable. The author further argues that Kant’s approach to laws, such as those governing kidney distribution, was formed (...) in part by considering and rejecting an assumption frequently employed in the bioethics literature, namely, that legal duties can be grounded directly in moral duties. The author explains some of Kant’s reasons for rejecting this assumption and concludes that arguments pertaining to the legality of kidney sales developed on the basis of Kant’s moral philosophy should no longer be considered tenable. (shrink)

Patient support tools have drawn on a variety of disciplines, including psychotherapy, social psychology, and social care. One discipline that has not so far been used to support patients is philosophy. This paper proposes that a particular philosophical approach, phenomenology, could prove useful for patients, giving them tools to reflect on and expand their understanding of their illness. I present a framework for a resource that could help patients to philosophically examine their illness, its impact on their life, and its (...) meaning. I explain the need for such a resource, provide philosophical grounding for it, and outline the epistemic and existential gains philosophy offers. Illness often begins as an intrusion on one’s life but with time becomes a way of being. I argue that this transition impacts on core human features such as the experience of space and time, human abilities, and adaptability. It therefore requires philosophical analysis and response. The paper uses ideas from Husserl and Merleau-Ponty to present such a response in the form of a phenomenological toolkit for patients. The toolkit includes viewing illness as a form of phenomenological reduction, thematizing illness, and examining illness as altering the ill person’s being in the world. I suggest that this toolkit could be offered to patients as a workshop, using phenomenological concepts, texts, and film clips to reflect on illness. I conclude by arguing that examining illness as a limit case of embodied existence deepens our understanding of phenomenology. (shrink)

Reproductive medicine, a sector of a health care system increasingly captured by the demands of the marketplace, is enmeshed in a drive to sell certain human bits and pieces, such as gametes, cells, fetal eggs, and fetal ovaries, for reproductive purposes. The ethical objection raised by Kant and Radin to the sale of human organs -that this is incompatible with human dignity and worth - also applies to these sales. Moreover, such sales nullify the reproductive paradigm, irretrievably replacing it with (...) a ma nufacturing paradigm. This represents a change in kind, not just of degree, in the way that we view our capacity to generate children and destroys our concept of reproduction as an essentially human activity. In the face of a struggle to retain those common ethical values at the foundation of reproductive medicine, this form of commodification of the human body should be viewed as ethically unacceptable. (shrink)

The range of opportunities people enjoy in life largely depends on social, biological, and genetic factors for which individuals are not responsible. Philosophical debates about equality of opportunities have focussed mainly on addressing social determinants of inequalities. However, the introduction of human bioenhancement should make us reconsider what our commitment to equality entails. We propose a way of improving morally relevant equality that is centred on what we consider a fair distribution of bioenhancements. In the first part, we identify three (...) main positions in the debate on bioenhancement and equality, and we show how each of them fails to meet the demands of a serious commitment to equality. In the second part, we formulate a new proposal that we think better promotes equality of opportunities: people from disadvantaged socio-economic backgrounds should be given access to bioenhancements while people from privileged socio-economic background should be prohibited from using them. We argue that those who are concerned about the inequality implications of bioenhancement should embrace this solution, rather than reject bioenhancement. (shrink)

Pain is far more than an aversive sensation. Chronic pain, in particular, involves the sufferer in a complex experience filled with ambiguity and paradox. The tensions thereby established, the unknowns, pressures, and oscillations, form a significant part of the painfulness of pain. This paper uses a phenomenological method to examine nine such paradoxes. For example, pain can be both immediate sensation and mediated by complex interpretations. It is a certainty for the experiencer, yet highly uncertain in character. It pulls one (...) to the present but also projects one outward to a feared or desired future. Chronic pain can seem located in the body and/or mind; interior to the self, or an alien other; confined to a particular point and/or radiating everywhere. Such fundamental paradoxes, existential and epistemological, can challenge those living with long-term pain. (shrink)

In Kidney for Sale by Owner: Human Organs, Transplantation, and the Market, I argued that the market is the most efficient and effective—and morally justified—means of procuring and allocating human organs for transplantation. This special issue of The Journal of Medicine and Philosophy publishes several articles critical of this position and of my arguments mustered in its support. In this essay, I explore the core criticisms these authors raise against my conclusions. I argue that clinging to comfortable, but unfounded, notions (...) that human body parts are not commodities, that the physician-patient relationship transcends commercial practices, and that medicine rises above market-place morality (where “market-place morality” is presented rhetorically as a criticism) leads to a real failure adequately to appreciate the complex reality of modern medicine. Denying the illicit moral intuitions that commodification of body parts is immoral or that it necessarily violates human dignity would benefit donors and recipients alike, while also reinforcing virtuous transplantation practice and policy. Honestly acknowledging the medical marketplace would shed light on what is often a hazy and shrouded policy setting. At stake is not solely the efficiency of procuring human organs for transplantation but also the recognition of the moral authority of persons over themselves. (shrink)

A scientific paradigm typically embraces research norms and values, such as truth-seeking, critical thinking, disinterestedness, and good scientific practice. These values should prevent a paradigm from introducing defective assumptions. But sometimes, scientists who are also physicians develop clinical norms that are in conflict with the scientific enterprise. As an example of such a conflict, we have analyzed the genesis and development of the shaken baby syndrome paradigm. The point of departure of the analysis is a recently conducted systematic literature review, (...) which concluded that there is very low scientific evidence for the basic assumption held by Child Protection Teams: when certain signs are present the infant has been violently shaken. We suggest that such teams have developed more value-based than scientific-based criteria when classifying SBS cases. Further, we suggest that the teams are victims of “groupthink,” aggravating the difficulties in considering critics’ questioning the criteria established by the teams. (shrink)

One of the strongest objections to the development and use of substantially life-extending interventions is that they would exacerbate existing unjust disparities of healthy lifespans between rich and poor members of society. In both popular opinion and ethical theory, this consequence is sometimes thought to justify a ban on life-prolonging technologies. However, the practical and ethical drawbacks of banning receive little attention, and the viability of alternative policies is seldom considered. Moreover, where ethicists do propose alternatives, there is scant effort (...) to consider their merits in light of developing world priorities. In response to these shortcomings, I distinguish four policy options and, on the basis of a plausible intuition about fairness, evaluate their implications for a fair distribution of healthy lifespans. I claim that even in developing nations it would be fairest to favor policies that promote equal access to at least one promising category of substantially life-extending intervention: calorie restriction mimetics. (shrink)

Promoting recovery has become more and more important in the care of patients with severe mental disorders such as psychosis. Recovery is a personal process of growth involving hope, self-identity, meaning in life, and responsibility. Obviously, these components pertain, at least in part, to a psychotherapeutic care perspective. Yet, up to now, recovery has mainly been taken into account in transforming health services and as a general framework for supportive therapy. Existential phenomenology abdicates a theoretical stance and considers issues such (...) as death anxiety, isolation, responsibility, and meaning. Thus, it is likely to provide some insight into the psychotherapeutic aspects of recovery. Furthermore, existential psychotherapy allows powerful insights for adopting a recovery-oriented attitude and to provide useful themes for discussing issues allowing patients to gain meaning and hope. This paper describes these elements to give clinicians insights into this complex topic. (shrink)

In this paper, I claim that the doctor-patient relationship can be viewed as a vessel of trust. Nonetheless, trust within the doctor-patient relationship has been impaired by managed care. When we conceive of trust as social capital, focusing on the role that it plays in individual and social well-being, trust can be viewed as a public good and a scarce medical resource. Given this, there is a moral obligation to protect the doctor-patient relationship from the cost-containment mechanisms that compromise its (...) ability to produce trust. (shrink)

Speciesist or biological accounts of moral status can be defended by showing that all members of Homo sapiens have a moral status conferring property. In this article, I argue that the most promising defense locates the moral status conferring property in the relational property of being biologically tied to other humans. This requires that biological ties ground moral obligations. I consider and reject the best defenses of that premise. Thus, we are left with compelling evidence that biological ties and membership (...) in a biological category like “species” ground neither moral obligations nor moral status. Because it is crucial to account for the moral significance of family bonds, I conclude by describing the sense in which biological ties matter morally. (shrink)