Bioethics

Symposium in Bioethics: "Health Rights: Individual. Collective. ‘National?’"

Bioethics 35-8By Mark D. White

There is a symposium in the latest issue of Bioethics (35/8, October 2021), edited by Michael Da Silva and Daniel Weinstock, on the topic of health rights that explores their ethical, political, and economics dimensions of "health rights"—the opening paragraph of the editors' introduction provides context and citations to supporting and critical literature:

‘Socio‐economic’ rights are a species of so‐called ‘positive’ right that call for performance of certain actions—most often the provision of particular goods and services—on the part of the rights claims’ purported corresponding duty‐bearers.1 Advocates of ‘socio‐economic’ rights to health, healthcare, or public health (‘health rights’) have produced several plausible theories that address some of the most pressing challenges for socio‐economic rights claims. Many critics still deny that moral health rights exist or that rights‐based approaches will best achieve health justice,2 but health rights theorists at least provide sophisticated answers to basic questions like ‘Who possesses the rights and their corresponding duties?’and ‘What are the nature, scope, and content of the duties?’Answers to these questions differ and will not convince all critics, but rights‐based approaches to the corner of bioethics devoted to health justice now at least constitute part of the scholarly mainstream.3 Regardless of their theoretical bona fides, in turn, health rights exist in many legal systems. The international right to health is well established and most domestic constitutions recognize rights to healthcare, if not broader rights to health or public health.4 Theorists should and do attempt to ‘make sense’ of this phenomenon.5

(The footnotes appear at the end of this post.)

As the rest of the introductory essay recognizes, and the papers in the symposium explore, a right to health, as with positive rights in general, is fraught with conflicts with negative rights (against interference and compulsion) as well as other positive rights that may compete with health rights in principle or along more practical concerns of resource scarcity.

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Footnotes to opening paragraph of introduction:

1 For good summaries, see Rumbold, B. E. (2017). The moral right to health: A survey of available conceptions. Critical Review of International Social and Political Philosophy, 20(4), 508–528; Hassoun, N. (2015). The human right to health. Philosophy Compass, 10(4), 275–283; Hassoun, N. (2020). The human right to health: A defense. Journal of Social Philosophy, 51(2), 158–179. On the less commonly discussed purported ‘right to public health’, see Wilson, J. (2016). The right to public health. Journal of Medical Ethics, 42(6), 367–375.
2 Gopal Sreenivasan provides one of the strongest arguments against moral health rights in Sreenivasan, G. (2012). A human right to health? Some inconclusive scepticism. Proceedings of the Aristotelian Society Supplementary Volume, 86, 239–265 and Sreenivasan, G. (2016). Health care and human rights: Against the split duty gambit. Theoretical Medicine and Bioethics, 37(4), 343–364, though he recognizes that legal rights exist and may be justified. Cohen, J. (2020). Paradigm under threat: Health and human rights today. Health and Human Rights Journal, 22(2), 309–312 has a nice, succinct overview of criticisms of rights‐based approaches to health justice and attempts to respond to such critiques.
3 The last two comments build on sources cited in note 1. For a succinct discussion focused on theorizing the international rights, see Wolff, J. (2012). The human right to health. W. W. Norton.
4 United Nations. (1966, December 16). International Covenant on Economic, Social and Cultural Rights, 993 UNTS 3, art. 12; Rosevear, E., Hirschl, R., & Jung, C. (2019). Justiciable and aspirational economic and social rights in national constitutions. In K. G. Young (Ed.), The future of economic and social rights (pp. 37–65). Cambridge University Press.
5 The language here is inspired by Nickel, J. W. (1987). Making sense of human rights: Philosophical reflections on the Universal Declaration of Human Rights. University of California Press. Wolff, op. cit. note 3 is an example of an attempt to ‘make sense’ of existing laws from a philosophical perspective.


Virtual Conference on "Teaching Ethics to Economists: Challenges & Benefits"

By Jonathan B. Wight

Conference Dates: October 21-22, 2021

Virtual Conference

LSBU Business School
&
London Centre for Business and Entrepreneurship Research

During the last 30 years, the conversation between economic theory and ethics has been restarted, after a period of interruption, generated by the positivist era in economics. We cannot ignore, in this revival, the role of the financial crisis, gender and racial inequality and now the divisions revealed by the unequal impacts of the pandemic. An important contribution has been the call for a professional economic ethics led by DeMartino (2011) and DeMartino and McCloskey (2016).

More recently, Dolfsma and Negru (2019) challenge the idea that ethics has no place in economics. Building on their ideas we ask: Is ethics important for the study of the economy and, if so, how should it be taught?

This two day conference will be of interest to lecturers and students in economics and business - and anyone with an interest in the future of the economics curriculum.

Link for the event & registration: 
https://www.eventbrite.co.uk/e/teaching-ethics-to-economists-challenges-benefits-tickets-170298187463 


Programme

Day One: Thursday 21 October

9.45am - Virtual housekeeping & Zoom functionality - Neil Hudson-Basing, Corporate Events Manager, LSBU

9.55am - Welcome Craig Duckworth, LSBU Business School, UK

10am - Introduction to the day. Economics and Ethics - what is the agenda?

10.30am - Revisiting the analytical relationship of Ethics and Economics María Isabel Encinar & Félix-Fernando Muñoz, Universidad Autónoma de Madrid, Spain

11.15am - Theoretical and ethical reductionism and the neglect of subjectivity in economics and economic education - Giancarlo Ianulardo, University of Exeter, UK

12pm - Lunch break

12.30pm - Keeping alive non-individualistic ethics in political economy: a review of concepts from Aquinas to Habermas Stefano Solari, University of Padua, Italy

1.15pm - Racism, the economy and ethics: where does it all begin? - Paolo Ramazzotti, University of Macerata, Italy

2pm - Teaching economic harm to economists - George DeMartino, University of Denver, USA

2.45pm - Comfort break

3pm - The fate of moral philosophy in the age of economic scientism: ethics and welfare economics in mainline economics - Peter Boettke, George Mason University, USA

3.45pm - Plenary: Reflections

4pm - End of Day One

______________________________________________________________________

Day Two: Friday 22 October

9.45am - Virtual housekeeping & Zoom functionality - Neil Hudson-Basing, Corporate Events Manager, LSBU

9.55am - Welcome and intro to Day Two Craig Duckworth, LSBU Business School, UK

10am - Managerial decision making: consequences and Consequentialism - Malcolm Brady & Marta Rocchi, Dublin City University, Ireland

10.45am - Economic curricular, pluralism and the Global South Michelle Groenewald, North- West University, South Africa

11.30am - Accounting as applied ethics: teaching a discipline - Wilfred Dolfsma, Wageningen University, Netherlands

12.15pm - Lunch break

12.45pm - Purusharthas: the human pursuit of wealth and welfare. The Indian approach to ethics and economics - V P Raghavan, Indira Gandhi National Centre for the Arts, India

1.30pm - Economics, ethics and deliberation

  • Ioana Negru, Lucian Blaga University of Sibiu, Romania
  • Imko Meyenberg, Anglia Ruskin University, Cambridge, UK
  • Craig Duckworth, LSBU Business School, UK

2.15pm - The kidney market debate: a retrospective on Becker and Elias - Jonathan Wight, University of Richmond, USA

3pm - Comfort break

3.15pm - Alfred North Whitehead on the education of the commercial class: its influence on Keynes Dennis Badeen, University of Hertfordshire, UK

4pm - Plenary: Reflections

4.15pm - End of Conference

*Times according to GMT

________________________________________________________________________________________________

This conference will be delivered virtually via Zoom. You will receive the joining instructions on the Monday before the event takes place.


Death with Dignity

By Jonathan B. Wight

“We have invented more health care than we can afford to deliver….We already ration. The United States denies more health care to more people than any other developed country in the world. We did that by leaving 50 million people out of the system (before the Affordable Care Act).”

“[For example] I don't believe you should give any extensive operations to anybody over 85. You should make sure that they're clean, they're loved, they're comfortable, they're pain-free, but we shouldn't be doing high-technology medicine on people over 85.”

--Richard D. Lamm, former Governor of Colorado

I’m not sure what Dick Lamm means by “give” extensive operations.  Perhaps better to clarify: we should not be spending public health dollars to do heroic medicine, given that we have millions of people still without access to basic care. But individuals should be free to spend their own private money on any frivolous medical interventions they want--including cryogenics, a solid-gold casket, and so on. People should have the right to do so, even if they don't have the right to my respect for such behavior.

There is something virtuous, I think, in being prudent—in showing proper regard for our future selves.  And that means taking care of ourselves, including with medical interventions.  But at what point should we (as people who aspire to live a life of meaning) step back and follow Being mortalAdam Smith’s conception of “superior” prudence. Do we have a duty to others to die gracefully—and not, for example, rack up hundreds of thousands of dollars in debt to prolong our own lives by a few weeks or months? 

Along this line, consider this post from John Kay:

“A rising proportion of medical expenditure is now devoted to prolonging the lives of the very old and the terminally ill. The costs of this are potentially unlimited.

“We should pause to ask ourselves the questions raised by the surgeon Atul Gawande in his book, Being Mortal. Perhaps the greatest challenges in modern healthcare are not those of meeting the spiraling cost of advanced medical technologies. They lie in accepting that we are all going to die, and learning to do so with dignity.”

--John Kay, in the Financial Times. 


Bioethics and Disagreement (in Journal of Medicine and Philosophy)

Mark D. White

Jrnl med philThanks to Jan Henderson's terrific blog The Health Culture, I bring you the latest issue of The Journal of Medicine and Philosophy (39/3, June 2014), which focuses on "Bioethics and Disagreement: Organ Markets, Abortion, Cognitive Enhancement, Double Effect, and Other Key Issues in Bioethics," and includes articles by James Stacey Taylor, Walter E. Block, Rob Goodman, and more. In fact, just check out Henderson's blog for the titles and abstracts--thanks, Jan!

 


JEBO special issue on Evolution

Jonathan B. Wight

David Sloan Wilson, John M. Gowdy and J. Barkley Rosser Jr have edited a fine collection of papers about the role of evolution and multi-level selection in a special issue of the Journal of Economic Behavior and Organization.  See here for a link to free articles (limited time offer):

http://evolution-institute.org/node/144/

For those new to this, multi-level selection theory basically argues that evolution works at more than one level.  In addition to individuals competing against other individuals, groups compete against other groups.  The dynamics of group behavior, including moral sentiments and ethical norms, are an important part of the conversation.  

This creates interesting dynamics, in which cooperation and sacrifice for the group can sometimes produce greater rates of survival and procreation.  Darwin was himself a fan of group selection theory.  

Then, in the 1970s, socio-biology fell out of favor, coincident with the rise of neoclassical economics, which posits selfish individualism.  David Sloan Wilson and others have been attempting to resurrect the social view of evolution.  Social economists have a lot at stake.


How must military medical ethics adapt to the realities of modern warfare?

Mark D. White

The latest issue of Bioethics (27/3, March 2013) features a brief but provocative paper by Steven H. Miles (University of Minnesota in Minneapolis) titled "The New Military Medical Ethics: Legacies of the Gulf Wars and the War on Terror":

United States military medical ethics evolved during its involvement in two recent wars, Gulf War I (1990–1991) and the War on Terror (2001–). Norms of conduct for military clinicians with regard to the treatment of prisoners of war and the administration of non-therapeutic bioactive agents to soldiers were set aside because of the sense of being in a ‘new kind of war’. Concurrently, the use of radioactive metal in weaponry and the ability to measure the health consequences of trade embargos on vulnerable civilians occasioned new concerns about the health effects of war on soldiers, their offspring, and civilians living on battlefields. Civilian medical societies and medical ethicists fitfully engaged the evolving nature of the medical ethics issues and policy changes during these wars. Medical codes of professionalism have not been substantively updated and procedures for accountability for new kinds of abuses of medical ethics are not established. Looking to the future, medicine and medical ethics have not articulated a vision for an ongoing military-civilian dialogue to ensure that standards of medical ethics do not evolve simply in accord with military exigency.


"Property in Human Biomaterials—Separating Persons and Things?"

Mark D. White

QuigleyMuireann Quigley (Centre for Social Ethics & Policy, School of Law, University of Manchester) has a fascinating paper in the latest issue of Oxford Journal of Legal Studies (32/4, Winter 2012) titled "Property in Human Biomaterials—Separating Persons and Things?":

The traditional ‘no property’ approach of the law to human biomaterials has long been punctured by exceptions. Developments in the jurisprudence of property in human tissue in English law and beyond demonstrate that a variety of tissues are capable of being subject to proprietary considerations. Further, among commentators, there are few who would deny, given biotechnological advances, that such materials can be considered thus. Yet, where commentators do admit human biomaterials into the realm of property, it is often done with an emphasis on some sort of separation from the person who is the source of those materials. One line of argument suggests that there is a difference between persons and things, which constitutes a morally justifiable distinction when it comes to property. This article examines whether the idea of separability can do the work of demarcating those objects that ought to be considered property from those that ought not to be. It argues that, despite the entailment of a separability criterion inherent in both the statutory and common law positions, and the support given to this by some commentators, it is philosophically problematic as the basis for delineating property in human tissue and other biomaterials. 


Special issue of Health Economics, Policy and Law on end-of-life care

Mark D. White

HEPLThe latest issue of Health Economics, Policy and Law (7/4, October 2012) is a special issue on th topic of end-of-life care, stemming from a workshop held by the London School of Economics/Columbia Health Policy Group in December 2010:

Introduction (Adam Oliver)

Comparing the United States and United Kingdom: contrasts and correspondences (Rudolf Klein)

The conventionally antithetical stereotypes of the United Kingdom and United States health care systems needs to be modified in the case of the elderly. Relative to the rest of the population, the over-65s in the United States are more satisfied with their medical care than their UK counterparts. There is also much common ground: shared worries about the quality of elderly care and similar attitudes towards assisted death. Comparison is further complicated by within country variations: comparative studies should take account of the fact that even seemingly polar models may have pools of similarity.

Evidence and values: paying for end-of-life drugs in the British NHS (Kalipso Chalkidou)

In January 2009, Britain's National Institute for Health and Clinical Excellence (NICE), following a very public debate triggered by its decision, six months earlier, provisionally to rule against the adoption by the National Health Service (NHS) of an expensive drug for advanced renal cancer, introduced a new policy for evaluating pharmaceuticals for patients nearing the end of their lives. NICE's so-called end-of-life (EOL) guidance for its Committees effectively advises them to deviate from the Institute's threshold range and to value the lives of (mostly) dying cancer patients more than the lives of those suffering from other, potentially curable, chronic or acute conditions. This article tells the story of the EOL guidance. Through looking at specific EOL decisions between 2009 and 2011 and the reactions by stakeholders to these decisions and the policy itself, it discusses the triggers for NICE's EOL guidance, the challenges NICE faces in implementing it and the policy's putative implications for the future role of NICE in the NHS, especially in the context of value-based reforms in the pricing and evaluation of pharmaceuticals, currently under consideration.

Valuing end-of-life care in the United States: the case of new cancer drugs (Corinna Sorenson)

New cancer therapies offer the hope of improved diagnosis to patients with life-threatening disease. Over the past 5–10 years, a number of specialty drugs have entered clinical practice to provide better systemic therapy for advanced cancers that respond to few therapeutic alternatives. To date, however, such advances have been only modestly effective in extending life and come with a high price tag, raising questions about their value for money, patient access and implications for health care costs. This article explores some of the key issues present in valuing end-of-life care in the United States in the case of advanced cancer drugs, from the difficult trade-offs between their limited health benefits and high costs to the technical, political and social challenges in assessing their value and applying such evidence to inform policy and practice. A number of initial steps are discussed that could be pursued to improve the value of advanced cancer care.

Setting priorities in and for end-of-life care: challenges in the application of economic evaluation (Charles Normand)

Health technology assessment processes aim to provide evidence on the effectiveness and cost-effectiveness of different elements of health care to assist setting priorities. There is a risk that services that are difficult to evaluate, and for which there is limited evidence on cost-effectiveness, may lose out in the competition for resources to those with better evidence. It is argued here that end-of-life care provides particular challenges for evaluation. Outcomes are difficult to measure, can take place over short time scales, and services can be difficult to characterise as they are tailored to the specific needs of individuals. Tools commonly used to measure health care outcomes do not appear to discriminate well in the end-of-life care context. It is argued that the assumption that units of time of different quality of life can simply be added to assess the overall experience at the end of life may not apply, and that alternative perspectives, such as the Peak and End Rule, might offer useful perspectives.

Delivering better end-of-life care in England: barriers to access for patients with a non-cancer diagnosis (Rachael Addicott)

The End of Life Care Strategy (Department of Health, 2008) radically raised the profile of end-of-life care in England, signalling the need for development in planning and delivery, to ensure that individuals are able to exercise genuine choice in how and where they are cared for and die. Research has indicated that there have been continuing difficulties in access to high-quality and appropriate support at the end of life, particularly for patients with a diagnosis other than cancer. This article uses research findings from three case studies of end-of-life care delivery in England to highlight some of the barriers that continue to exist, and understand these challenges in more depth. Access to high-quality and appropriate end-of-life care has been a challenge for all patients nearing the end of life. However, the findings from this research indicate that there are several interrelated reasons why access to end-of-life care services can be more difficult for patients with a non-cancer diagnosis. These issues relate to differences in disease trajectories and subsequent care planning, which are further entrenched by existing funding arrangements.

US health care: the unwinnable war against death (Daniel Callahan)

For well over 40 years, the United States has struggled to improve end-of-life care. This effort, heavily focused on living wills, hospice and improved doctor–patient communications and palliative care, has been a modest success only. Both doctors and patients are often unwilling to accept the fact that death is on the way – only 25% of Americans have an advance directive. Advances in medical technology have provided more ways of keeping dying patients alive, making the line between living and dying harder to discern. The way physicians are paid promotes the use of technology not for talking with patients. Underlying these practical problems is a culture of American medicine with deep historical roots: that medical progress should be unending and is a moral imperative, that death is the greatest enemy and that cure, not care, is the primary goal. A better balance between care and cure is needed.

Stealing on insensibly: end of life politics in the United States (Lawrence D. Brown)

Because the United States often seems (and seems eager to present itself as) the home of the technological imperative and of determination to brand all challenges to it in end-of-life care as a descent into death panels, the prospects look unpromising for progress in US public policies that would expand the range of choices of medical treatments available to individuals preparing for death. Beneath this obdurate and intermittently hysterical surface, however, the diffusion across US states and communities of living wills, advanced directives, palliative care, hospice services and debates about assisted suicide is gradually strengthening not so much ‘personal autonomy’ as the authority, cultural and formal, of individuals and their loved ones not merely to shape but to lead the inevitably ‘social’ conversations on which decisions about care at the end of life depend. In short, the nation appears to be (in terms taken from John Donne's mediations on death) ‘stealing on insensibly’ – making incremental progress toward the replacement of clinical and other types of dogma with end-of-life options that honor the preferences of the dying.

End-of-life care for patients with dementia in the United States: institutional realities (Michael Gusmano)

Few are satisfied with end-of-life care in the United States. For families and friends of people with dementia, end-of-life care is particularly frustrating. Providing better end-of-life care to people with dementia is urgent because the prevalence of the disease is increasing rapidly. Dementia is currently the seventh leading cause of death in the United States and fifth leading cause of death among people aged 65 years and older. By 2050, there will be around 19 million people with Alzheimer's disease. This article reviews ethical and policy challenges associated with providing end-of-life care for people with dementia in the United States. I explain how disagreements about the meaning of futility lead to poor care for people with dementia. Most people agree that we should not provide care that is futile, but there is little agreement about how futility should be defined. US policies and politics clearly tip the balance in the direction of treatment, even in the face of strong evidence that such care does more harm than good. Although we may never reach a consensus, it is important to address these questions and think about how to develop policies that respect the different values.

Dementia, death and advance directives (Jonathan Wolff)

This article considers the ethics of advance directives, especially in relation to conditions such as dementia. For some choices, such as over whether one's life should end at home or in a hospice, advance directives can be very enlightened and helpful. For others, such as those to end the life of an autonomous subject, against their will, have no moral appeal and would rightly be ignored. In a wide range of intermediate cases, given our typical lack of insight into how changes in our health condition will affect us in other ways, we should be very cautious indeed in promoting the use of advance directives in end-of-life decisions, at least where a reasonable quality of life remains. There may be some reasons for giving priority to the earlier autonomous self over a later, contented but non-autonomous self, but these reasons seem far from compelling.


Symposium on Obamacare in The Journal of Law, Medicine & Ethics

Mark D. White

JLMEThe latest issue of The Journal of Law, Medicine & Ethics (40/3, Fall 2012) features a symposium titled "The Health Care Reform Law (PPACA): Controversies in Ethics and Policy," based on a conference held at the Medical University of South Carolina in October 2011 and organized as a group of point-counterpoint discussions focusing on "the responsibilities of individuals versus those of society to provide health care, the morality of market-based health care reforms, the effectiveness of consumer-driven health care reforms, and the role of the principle of justice in grounding health care reform" ("Introduction," p. 523).

Introduction (Robert M. Sade)

Physicians Have a Responsibility to Meet the Health Care Needs of Society (Allan S. Brett)

Medical Responsibility (Ronald Hamowy)

Market-Based Reforms in Health Care Are Both Practical and Morally Sound (James Stacey Taylor)

Government Intervention in Health Care Markets Is Practical, Necessary, and Morally Sound (Len M. Nichols)

Expanding Choice through Defined Contributions: Overcoming a Non-Participatory Health Care Economy (Robert E. Moffit)

Cost-Sharing under Consumer-Driven Health Care Will Not Reform U.S. Health Care (John P. Geyman)

Justice and Fairness: A Critical Element in U.S. Health System Reform (Paul T. Menzel)

No Theory of Justice Can Ground Health Care Reform (Griffin Trotter)


Romney, Freedom, and Abortion

Jonathan B. Wight

Mitt Romney seems like a nice guy. He clearly is a natural-born leader in the sense that he rises to top of his cohorts, whether in the Mormon Church, the Olympics, and the political scene. But he reeks of falsehood about his core beliefs; he seems a chameleon willing to say whatever he thinks will sell. A huge example is his successful health care reform in Massachusetts requiring mandates that now he disavows. A second is his former commitment to libertarian ideals of freedom and small government when it affects women's health, which again he now disavows.

Slate has a fascinating account of Romney's flip-flops on abortion policy and the personal and political calculations that likely lay behind it. The Mormon Church is mainly pro-life, with exceptions for rape and health of mother. As a bishop in the church Romney counseled a woman in her hospital bed not to have an abortion even though her life was endangered.

Later, when running for the Senate in liberal Massachusetts, Romney hired a consultant who told him he would never win unless he switched to pro-choice. In 1994 Romney and his wife attended Planned Parenthood fundraiser and donated to it. Here is Romney in 1994 supporting his pro-choice stance and justifying it based on his own moral sentiments:

"Many, many years ago, I had a dear, close family relative that was very close to me who passed away from an illegal abortion. It is since that time that my mother and my family have been committed to the belief that we can believe as we want, but we will not force our beliefs on others on that matter. And you will not see me wavering on that."

Later, running for governor of Massachusetts in 2002, Romney pledged a commitment to liberal ideals:

"Believing in people is protecting their freedom to make their own life choices, even if their choice is different than yours. That choice is a deeply personal one, and the women of our state should make it based on their beliefs, not mine, not the government's."

Romney now says that in 2006 he had a conversion back to pro-life because of his consideration of stem-cell research with embryos. That is probably about the same time he began to plot his national ambition to reach the presidency.

Abortion and stem-cell controversies are painful and difficult. Liberal intellectual reasoning leads people to their own mountains of conceit and prejudice against those who hold a more primitive moral sentiments (and Catholic view) that human life begins at conception. In the future we will learn much more—and it would not surprise me if science comes to find that some consciousness exists in an embryo or even in a sperm and egg. The Catholic intuition may turn out to be closer to the truth.

That does not mean its abortion stance is the correct one; Romney's 1994 and 2002 position on abortion may be the best we have at the moment, given all hard and bad choices.