Is aging a preventable or curable disease?

The question of whether aging is a disease is old and controverted. Three possible positions are outlined: (i) aging is a natural event, not a disease; (ii) aging is a disease, to be combated by medical knowledge and skills; and (iii) aging, while natural, can be treated as if it is a disease and efforts made to lessen its undesirable impact. The last position seems, de facto, the one that is being pursued by contemporary medicine; however, in such a pursuit, important issues will be raised of intergenerational justice in paying for advances in medicine, and the need to balance the medical goals of care for aged people against other important social needs.

Managed care and the goals of medicine

The goals of medicine encompass the relief of pain and suffering, the promotion of health and the prevention of disease, the forestalling of death and the promoting of a peaceful death, and the cure of disease when possible and the care of those who can not be cured. Managed care, as a system of integrated healthcare delivery designed to control costs, is not, in principle, incompatible with the goals of medicine, but in practice it may well be, depending on whether profit is sought, whether the integrity of physicians' medical judgment is protected, and whether government regulations control managed care practices to prevent abuse and to enhance the quality of care.

Frustrated mastery. The cultural context of death in America

The care of dying patients as a problem in the United States cannot be well understood apart from understanding the way in which American culture has responded to the problem of death. This country seems unusual among developed countries in its passion to conquer death, often acting as if death were simply one more disease to be overcome. American medicine has been influenced by this background culture, while adding some idiosyncratic features of its own. A powerful attraction to technology, a fear of malpractice litigation, and a fundamental ambivalence about the response physicians should have to death help to explain why the care of dying patients has been so difficult, so controversial, and so troubling to both the medical and the lay communities.

Long-acting contraceptives. Ethical guidance for policymakers and health care providers

Realizing the promise of long-acting contraceptives depends on continuing efforts to distinguish appropriate from inappropriate policies and practices. The current debates concerning Norplant and other long-term methods generally have based ethical judgment on too slim a reed. It is insufficient and overly divisive to limit the tools of analysis to questions of freedom and coercion. A richer perspective is needed. We have sketched out an alternative approach that rests on a close, case-by-case analysis attentive to the social dimension and consequences of contraceptive decisionmaking, as well as to the individual interests at stake. The approach also takes special note of the need for access to long-acting contraceptive, the possibility for mistaken nonuse as well as mistaken use, and our country's past and present biases and power imbalances. We do not claim that this method will make judgments about justifiable or unjustifiable influence easy or automatic. However, it should prove adept at underscoring the factors that require particular scrutiny. Perhaps more importantly, the approach highlights that influences for the use of long-acting contraceptives ought to be judged, not merely dismissed.

Managed care in mental health: the ethical issues

Praise and blame of managed mental health care are on the rise on many fronts, including allegations that it could adversely affect quality of care, access to care, the physician/patient relationship, and informed patient choice. Given the heterogeneity among managed mental health care organizations--each with differing practices--it is difficult to sift the ethically defensible concerns from the indefensible ones. In this paper we identify and examine the different moral concerns about managed mental health care and mark which problems have been addressed or are in need of resolution. We also identify which problems are unique to managed mental health care.

Setting limits: a response

Setting Limits: Medical Goals in an Aging Society was published in 1987, and immediately incurred considerable criticism because of its contention that age-based health care rationing could become necessary in the future as the baby boom generation aged and retired. That argument was considered to be ageist, discriminatory, and dangerous, and the ensuing debate generated a large number of books and articles. A response is offered to the criticisms, suggesting that we will not be able to evade the problem as easily as some critics have proposed, and that an age-limit proposal should be compared with other unpleasant choices, not with an ideal world.