Principlism and communitarianism

The decline in the interest in ethical theory is first outlined, as a background to the author's discussion of principlism. The author's own stance, that of a communitarian philosopher, is then described, before the subject of principlism itself is addressed. Two problems stand in the way of the author's embracing principlism: its individualistic bias and its capacity to block substantive ethical inquiry. The more serious problem the author finds to be its blocking function. Discussing the four scenarios the author finds that the utility of principlism is shown in the two scenarios about Jehovah's Witnesses but that when it comes to selling kidneys for transplantation and germline enhancement, principlism is of little help.

The future of the medical profession between bioethics and the market: a final comment

For a variety of historical and professional reasons the field of bioethics has paid little attention to the market. It has tended to treat the market with suspicion or hostility. Now, however, the market must be taken seriously. It has become a world-wide force in health care, and there is every reason to believe it will remain strong in the future. For that reason, it is wise to see what can be taken from the market, rather than simply dismiss it altogether. The market has various aspects: a theory of human nature, a view of human behavior, and an ideological aspect, with proponents stressing the necessary connection between political and market freedom. This article argues that only its view of human behavior should be accepted, particularly the possibility of using incentives, positive and negative, to change behavior. That can be helpful in health care, whereas the market's view of human nature should be rejected.

Job-based health insurance. Who has the duty to lead?

A noted medical ethicist argues that only the business community has the collective power and resources to create a "sustainable medicine" for the nation's health care. But will employers have sufficient incentive and motivation to do so?

Health care for children: a community perspective

There are two puzzles about health care for children that need explanation. Why is it the sentimentality Americans express about children has not been backed by solid health care programs? If children are to have good health care, how can a case for their high priority be made, particularly in light of the fact that their health is the best of all age groups in the country? The first question is explored, but the second question is the focus of this paper. A priority system for health care is proposed, and at the same time an argument is presented for why children should have a high priority despite their generally good health.

Judging the future: Whose fault will it be?

This paper looks at the future from the perspective of the way in which present thinking can influence what the future might be. It assumes that history shapes the future and that the present generation is in a position to shape it. It looks at the future of medicine as a science and a professional discipline, of health care as policy and politics, of culture and ideology as forces shaping medicine and health care, and of biomedical ethics as an influential source of wisdom and perspective. The paper argues that a strong future for bioethics requires a broad rather than a reductionistic vision of its proper work.

Oregon's first year: the medicalization of control

The results of Oregon's first year with physician-assisted suicide raise two questions. First, how will it be possible to evaluate what is actually going on in Oregon if there is no public access to the records and if physicians are shielded by patient confidentiality rules? The second question is whether the public understood that many, if not most, of those who want physician-assisted suicide want it not to relieve suffering as ordinarily understood but to maintain control over their dying, something that may not correlate at all with suffering from illness and disease. This commentary reviews the existing evidence from the Netherlands and suggests that abuse of the vulnerable will likely occur in Oregon over time. It also reviews the insufficiency of the data emerging from Oregon. Finally, it addresses the various issues raised by other commentators to the main article.

Medicine and the market: a research agenda

One of the most important developments in international medicine over the past two decades has been a turn to the market as a way of coping with rising costs and responding to calls for more freedom from government control. A full moral evaluation of the relationship of medicine and the market requires asking a wide range of questions bearing on the meaning and impact of market strategies on the economics of health care and on the clinical and public health outcomes of those strategies. A number of the leading questions are presented and some provisional answers offered.

Balancing efficiency and need in allocating resources to the care of persons with serious mental illness

The care of patients with serious mental illness, for whom a cure is unlikely and costs are high, is difficult to justify using ordinary standards of efficient resource allocation. The author examines the difficulties of using conventional utilitarian, cost-benefit, moral, and political arguments to justify allocation of resources to the care of persons with serious mental illness and offers an alternative approach to this problem based on the goals of medicine. Although care for persons with serious mental illness may not meet the usual standards of efficient health care spending, their treatment is justified by central and long-standing goals of medicine such as relief of pain and suffering and care of those who cannot be cured. This approach suggests that the idea of efficiency in health care spending should be adapted to the goals of medicine rather than making those goals adapt to the idea of efficiency.