Journal of Medicine and Philosophy - recent issues

Individual Responsibility and Solidarity in European Health Care: Further Down the Road to Two-Tier System of Health Care

Ter Meulen, R., Jotterand, F. — 2008-06-20

Bonuses as Incentives and Rewards for Health Responsibility: A Good Thing?

Schmidt, H. — 2008-06-20

Bonuses, as incentives or rewards for health-related behavior, feature prominently in German social health insurance. Their goal is centered around promoting personal responsibility, but reducing overall health-care expenditure and enabling competition between sickness funds also play a role. The central position of personal responsibility in German health-care policy is described, and a framework is offered for an analysis of the ethical issues raised by policies seeking to promote responsibility. The framework entails seven tests relating to: solidarity; equality and equity; intrusiveness; attributability and opportunity of choice; evidence, rationale, and feasibility; affected third parties; and coherence. It is contended that a focus on tests, in particular from within contractualism, is the most appropriate way of addressing the question of health responsibility in pluralistic societies. However, taken by themselves, the tests also allow an identification of the key ethical issues by particular policies, which are illustrated by applying the framework to particular bonus polices.

Organizational Reform and Health-care Goods: Concerns about Marketization in the UK NHS

Cribb, A. — 2008-06-20

This paper uses the recent history of marketization and privatization in the UK National Health Service as a case study through which to explore the relationship between health-care organization and health-care goods. Phases and processes of marketization are briefly reviewed in order to show that, although the scope of both marketization and privatization reforms have, until recently, been very heavily circumscribed (and can only be understood in the context of the rise of managerialism), they have nonetheless had a major impact on the "value field" of UK health services. The second half of the paper draws upon the concerns of the critics of market-style reforms to set out and explore the ways in which organizational reform and the shifts in institutional norms consequent upon it construct health-care goods and argues that the investigation of this organization-goods axis ought to have a central place in health-care ethics.

Market Reforms in Swedish Health Care: Normative Reorientation and Welfare State Sustainability

Bergmark, A. — 2008-06-20

Although the impact of market reforms in Swedish health care stands out as not very far-reaching in an international comparison, it represents a route away from the features and basic values normally associated with the Swedish or Scandinavian model. Summarizing the development over the last decades, we may identify signs of sustainability as well as change. Popular support for public provision and a robust institutional structure make far-reaching alterations of existing structures less feasible, although most visible changes this far—incremental though they may be—represent a change in which the normative foundations of the Swedish model are challenged.

Increasing Individual Responsibility in Dutch Health Care: Is Solidarity Losing Ground?

Ter Meulen, R., Maarse, H. — 2008-06-20

This article presents various developments in Dutch health care policy toward a greater role for individual financial responsibility, such as cost-control measures, priority setting, rationing, and market reform. Instead of the collective responsibility that is characteristic of previous times, one can observe in government policies an increased emphasis on the need for individuals to take care of one’s own health and health care needs. Moreover, surveys point to decreasing levels of public support for "unlimited" solidarity and "irresponsible" health behavior. This article attempts to answer the question of how these policies and public attitudes are limiting the ethical principles of solidarity and equal access to care that have long guided Dutch health care policy making. The authors argue that from a moral point of view, the increased emphasis on individual responsibility is acceptable as long as it does not affect solidarity with those weak and vulnerable groups who are not able to take individual responsibility, such as the demented and mentally handicapped.

Europe and the United States: Contrast and Convergence

Callahan, D. — 2008-06-20

Though the health care systems of the United States and the European countries are very different, they are being buffeted by similar problems: rising health care costs caused by aging populations, technology, and rising public demand and expectations. The primary difference is that the US system is heavily privatized, whereas the European systems are heavily government run or operated. But the latter systems are increasingly open to market ideas and practices while the US is steadily being pushed toward a stronger government role. This article offers some speculation about their gradual convergence in the years ahead.

Metaphysical Problems in the Philosophy of Medicine and Bioethics

Hinkley, A. E. — 2008-05-14

The Prototype Resemblance Theory of Disease

Sadegh-Zadeh, K. — 2008-05-14

In a previous paper the concept of disease was fuzzy-logically analyzed and a sketch was given of a prototype resemblance theory of disease (Sadegh-Zadeh (2000). J. Med. Philos., 25:605–38). This theory is outlined in the present paper. It demonstrates what it means to say that the concept of disease is a nonclassical one and, therefore, not amenable to traditional methods of inquiry. The theory undertakes a reconstruction of disease as a category that in contradistinction to traditional views is not based on a set of common features of its members, that is individual diseases, but on a few best examples of the category, called its prototypes, and a similarity relationship such that a human condition is considered a disease if it resembles a prototype. It enables new approaches to resolving many of the stubborn problems associated with the concept of disease.

Four Queries Concerning the Metaphysics of Early Human Embryogenesis

Howsepian, A. A. — 2008-05-14

In this essay, I attempt to provide answers to the following four queries concerning the metaphysics of early human embryogenesis. (1) Following its first cellular fission, is it coherent to claim that one and only one of two "blastomeric" twins of a human zygote is identical with that zygote? (2) Following the fusion of two human pre-embryos, is it coherent to claim that one and only one pre-fusion pre-embryo is identical with that postfusion pre-embryo? (3) Does a live human being come into existence only when its brain comes into existence? (4) At implantation, does a pre-embryo become a mere part of its mother? I argue that either if things have quidditative properties or if criterialism is false, then queries (1) and (2) can be answered in the affirmative; that in light of recent developments in theories of human death and in light of a more "functional" theory of brains, query (3) can be answered in the negative; and that plausible mereological principles require a negative answer to query (4).

Treating Humanity as an Inviolable End: An Analysis of Contraception and Altered Nuclear Transfer

Masek, L. — 2008-05-14

I argue that contraception is morally wrong but that periodic abstinence (or natural family planning) is not. Further, I argue that altered nuclear transfer—a proposed technique for creating human stem cells without destroying human embryos—is morally wrong for the same reason that contraception is. Contrary to what readers might expect, my argument assumes nothing about the morality of cloning or abortion and requires no premises about God or natural teleology. Instead, I argue that contraception and altered nuclear transfer are morally wrong because they fail to treat humanity as an inviolable end.

The Beginning of Individual Human Personhood

Penner, P. S., Hull, R. T. — 2008-05-14

Even for persons who hold to the ethical acceptance of abortion practices in general, questions of detail often arise. If you assume the distinction between the physical human organism alone and the person that is associated with that organism, then you must face the question of whether it is permissible to abort a fetus if the corresponding person has come into being. We take the position that the abortion of a fetus that has achieved this level of development should be declared unethical except in special circumstances. Our purpose here is to identify the point in the development of the fetus that serves as the marker for this level.

Colonizing Bioethics

Iltis, A. — 2008-05-14

Rethinking the Conceptual and Empirical Foundations of Clinical Ethics

McCullough, L. B. — 2008-02-01

The five papers in the 2008 "Clinical Ethics" number of the journal address the conceptual and empirical foundations of clinical ethics. Three articles take up the concept of professionalism in medicine, exploring its possibilities and implications. The fourth article provides a distinctive, phenomenological account of the "placebo effect," a vexing topic of surprising durability in the clinical setting. The final article, a systematic review of the qualitative literature on bedside rationing of resources, creates an empirical foundation for philosophical analysis and argument of a distinctive kind.

Professionalism's Facets: Ambiguity, Ambivalence, and Nostalgia

Erde, E. L. — 2008-02-01

Medical educators invoke professionalism as a core competency in curricula. This paper criticizes classic definitions. It also identifies some negative traits of medicine as a profession. The call to professionalism is naive nostalgia. Straightforward didactics in professionalism cannot do the desired work in medical education. The most we can say is that students should adopt the good aspects of professionalism and the profession should stop being some of what it has been. This is a platitude. If the notion is to be more than shallow, each student and practitioner will have to engage in much dialogue, reflection and refinement over many years.

Moral Damage to Health Care Professionals and Trainees: Legalism and other Consequences for Patients and Colleagues

Rentmeester, C. A. — 2008-02-01

Health care professionals’ and trainees’ conceptions of their responsibilities to patients can change over time for a number of reasons: evolving career goals, desires to serve different patient populations, and changing family obligations, for example. Some changes in conceptions of responsibility are healthy, but others express moral damage. Clinicians’ changes in their conceptions of what they are responsible for express moral damage when their responses to others express a meager, rather than robust, sense of what they owe others. At least two important expressions of moral damage in the context of health care are these: callousness and divestiture. Callousness describes the poor condition of a clinician's capacity for moral perception; when her capacity to accurately appreciate features of moral relevance that configure others’ needs, vulnerabilities, and desert of care diminishes, such that she fails to respond with care to those for whom she has duties to care, she is callous. Callousness has been explored in detail elsewhere,1 and so the focus of this paper is divestiture. A clinician divests when the value of responding with care to others becomes less centrally and importantly constitutive of his personal and professional identity. Divestiture has important consequences for patients and health professions education, which I will explore here.

An Analysis of Candidate Ethical Justifications for Allowing Inexperienced Physicians-in-Training to Perform Invasive Procedures

Mercurio, M. R. — 2008-02-01

Allowing relatively inexperienced physicians-in-training to perform invasive medical procedures is a widely accepted practice, generally felt to be justified by the need to train future generations of physicians. The ethical justification of this practice, however, is rarely if ever explored in any depth. This essay examines the moral issues associated with this practice, in the setting of a specific clinical scenario involving the emergency intubation of a critically ill newborn. The practice is ultimately shown to be justified based not only on the needs of society and future patients but also on the best interests of the patient being treated. However, several important qualifications need to be satisfied in order for this practice to be ethically permissible. The arguments and qualifications presented can be extended to clinical situations beyond the specific scenario discussed and are relevant to a wide range of medical and surgical settings.

A Phenomenology of the 'Placebo Effect': Taking Meaning from the Mind to the Body

Frenkel, O. — 2008-02-01

Most mainstream attempts to understand the "placebo effect" invoke expectancy theory, arguing that expecting certain outcomes from a treatment or intervention can manifest those outcomes. Expectancy theory is incompatible with the phenomena of placebo responses, more appropriately named "meaning responses." The expectancy account utilizes reflexive consciousness to connect a world of conceptual representations to mechanical physiology. An alternative account based upon Merleau-Ponty's motor intentionality argues that the body understands and is capable of responding to meanings without the need for any conceptual or linguistic content. A motor intentional framework of meaning poses dramatic implications for the interpretation of clinical trials and in the clinical practice of medicine. Most strongly, it argues that the empathic physician can facilitate the physiologic effects of treatments through skillful participation and manipulation of the meaning response.

How Physicians Allocate Scarce Resources at the Bedside: A Systematic Review of Qualitative Studies

Strech, D., Synofzik, M., Marckmann, G. — 2008-02-01

Although rationing of scarce health-care resources is inevitable in clinical practice, there is still limited and scattered information about how physicians perceive and execute this bedside rationing (BSR) and how it can be performed in an ethically fair way. This review gives a systematic overview on physicians’ perspectives on influences, strategies, and consequences of health-care rationing. Relevant references as identified by systematically screening major electronic databases and manuscript references were synthesized by thematic analysis. Retrieved studies focused on themes that fell under three major headings: (i) conditions and influences of BSR, (ii) strategies of BSR, and (iii) consequences of BSR. The range of themes indicates that physicians’ rationing behavior is highly variable, strongly influenced by context-related factors, and consists mainly of implicit rationing strategies. Torn between patient advocacy and the obligation to contain costs, physicians experience various role conflicts. The development of explicit rationing strategies seems necessary to avoid arbitrary BSR and allow a fair allocation of health-care resources.