Daniel Wikler

Basic curricular goals in medical ethics.

Formal teaching of ethics in the medical school curriculum has increased greatly during the past 15 years. Yet, schools vary in how much attention they give the subject, and even those that do offe...

Who Should be Blamed for Being Sick

That individuals are responsible for staying healthy is becoming a truism of health promotion and health policy. However, it is unclear what the slogan means, whether it is true, and what the consequences would be or should be if it is. A careful examina tion of the contexts in which the notion of personal responsibility for health occurs re veals a number of distinct arguments for different policy ends, each relying in turn on key unstated assumptions whose validity is doubtful. There is no disputing the minimal claim that most of us would be healthier if we took better care of ourselves. However, assignment of responsibility for health to the individual is usually part of a more far- reaching reassessment of obligations and entitlements in health care and health policy. A assessment of the concept of personal responsibility for health should precede any attempt to draw broad conclusions on rights and duties in maintaining health.

Persuasion and coercion for health: ethical issues in government efforts to change life-styles.

Millions of people live unhealthy or even destructive life-styles. While the government is widening its involvement in life-style reform it may be faced with problems of an ethical nature. 3 possible goals of health behavior reform can be stated: 1) health as a goal in itself 2) fair distribution of burdens caused by illness and 3) maintenance and improvement of the general welfare. The government should refrain from interventions that could be considered coercive and/or paternalistic thus compromising the autonomy of the individuals and use health education whenever possible. Targest for government intervention should also be commercial and social forces that cause or support life-threatening behavior. One must also consider the fact that people who take chances with their health place a significant financial burden upon society but even if this behavior is voluntary there is not necessarily justification for intervention by the state. A national health insurance program with mandatory membership should be considered and also allow people with self-destructive life-styles to assume the cost of their habits. The most efficient way to reduce the cost of health care would certainly seem a drastic change in health behavior without relying on any coercive or intrusive programs. Health education while providing information alerts people to the consequences of their acts. There is however the danger that reform efforts may become moralistic being an imposition of the preferences and values of 1 group over another.

Guidance on priority setting in health care (GPS-Health): the inclusion of equity criteria not captured by cost-effectiveness analysis

This Guidance for Priority Setting in Health Care (GPS-Health), initiated by the World Health Organization, offers a comprehensive map of equity criteria that are relevant to health care priority setting and should be considered in addition to cost-effectiveness analysis. The guidance, in the form of a checklist, is especially targeted at decision makers who set priorities at national and sub-national levels, and those who interpret findings from cost-effectiveness analysis. It is also targeted at researchers conducting cost-effectiveness analysis to improve reporting of their results in the light of these other criteria.The guidance was develop through a series of expert consultation meetings and involved three steps: i) methods and normative concepts were identified through a systematic review; ii) the review findings were critically assessed in the expert consultation meetings which resulted in a draft checklist of normative criteria; iii) the checklist was validated though an extensive hearing process with input from a range of relevant stakeholders.The GPS-Health incorporates criteria related to the disease an intervention targets (severity of disease, capacity to benefit, and past health loss); characteristics of social groups an intervention targets (socioeconomic status, area of living, gender; race, ethnicity, religion and sexual orientation); and non-health consequences of an intervention (financial protection, economic productivity, and care for others).

Can we learn from eugenics

Eugenics casts a long shadow over contemporary genetics. Any measure, whether in clinical genetics or biotechnology, which is suspected of eugenic intent is likely to be opposed on that ground. Yet there is little consensus on what this word signifies, and often only a remote connection to the very complex set of social movements which took that name. After a brief historical summary of eugenics, this essay attempts to locate any wrongs inherent in eugenic doctrines. Four candidates are examined and rejected. The moral challenge posed by eugenics for genetics in our own time, I argue, is to achieve social justice.

Ethical Challenges In Long-Term Funding For HIV/AIDS

The global response to the AIDS pandemic aims for universal access to treatment and for pursuing every possible avenue to prevention. Skeptics, doubting that the huge increases in current funding levels needed for universal treatment will ever happen, would scale back antiretroviral treatment in favor of more cost-effective preventive interventions. Economics, politics, and science figure in this debate. But there is also a question of ethical principle: Is there a moral imperative to emphasize treatment, even if emphasizing prevention would save more lives? The authors examine moral arguments that address this question, and come down on the side of saving the most lives via prevention.

Laying ethical foundations for clinical research.

^len^aThis section looks back to some ground-breaking contributions to public health, reproducing them in their original form and adding a commentary on their significance from a modern-day perspective. Jon Harkness, Susan Lederer and Daniel Wikler review the 1966 paper by Henry K. Beecher on ethics and clinical research. The original article is reproduced from The New England Journal of Medicine by permission of the Massachusetts Medical Society.

Not Dead, Not Dying? Ethical Categories and Persistent Vegetative State

Not Dead, Not Dying? Ethical Categories and Persistent Vegetative State How shall we regard those in persistent vegetative state? They are periodically awake, and their bodies breathe and digest on their own. These traits bespeak life. Yet they are not conscious and never will be: subjectively, this is death. Similarly, they may be, except neurologically and psychologically, quite healthy, capable of remaining in their condition for many years with only minimal care. Yet in considering treatment options we class them with the dying, perplexed over the permissibility of withholding care and letting patients die with dignity. Given these uncertainties, should patients in persistent vegetative state be maintained? A growing societal consensus answers in the negative. I support this conclusion, but puzzle over the rationale for it. The kind of reasoning that has been used in deciding-to-die cases of the past two decades has, I believe, begun to fail us. New kinds of cases are being discussed in an old, increasingly obsolete vocabulary. Persistent vegetative state, I further believe, is a case in point. Indeed, our consideration of persistent vegetative state permits two distinct views of its place in this evolution. In one aspect, it represents a relatively new kind of problem, the disposition of patients whose lives are stable but not worth living. But persistent vegetative state can also be seen as the last stage of another development: the changing definition of death. Likewise, persistent vegetative state can be conceived either as the lowest-functioning phase of life, or as the highest-functioning phase of death; the ethics of treatment can be discussed under either rubric. These two ways of construing the problem point to somewhat different laws and clinical practices, and the choice between them will affect our treatment not only of patients in persistent vegetative state but also of those in less debilitated conditions. The Changing Context of Decisions About Dying Moral problems concerning the treatment of patients in persistent vegetative state are almost always discussed in the context of debates over the disposition of the dying. But for both obvious and subtle reasons, these issues are different in character, and concepts that facilitate deliberation in one area may have less application to the other. Nevertheless, our dilemma in deciding on treatment of vegetative patients benefits by taking into account the recent history of medical decisionmaking about dying. Though the numerous court cases and celebrated examples do not arrange themselves in any neat pattern, their character has gradually evolved. In particular, there have been important changes in the kinds of conditions considered for nontreatment, in the means considered to bring about death, and in the nature of the particular rights asserted by or on behalf of the patient. In each case, the trend is toward less specifically medical circumstances, measures, and roles. This, I contend, is a significant source of uncertainty in our reasoning about the ethics of withdrawing care from patients in persistent vegetative state as well as those with coma and dementia. Conditions Not Treated: With the passage of time, elective nontreatment is being considered for patients with less serious and less terminal ailments. The earliest clinical cases concerned those in the most debilitated condition of all, death of the entire brain. The perceived need to justify nontreatment of the brain dead seems to have been a key factor in the redefinition of death, [1] a step that, in effect, licensed the withdrawal of care from these patients at the moment of diagnosis. In the years since the new definition was proposed and enacted by most states, nontreatment has been judicially approved for patients in less dire circumstances. The Quinlan case involved what was diagnosed as persistent vegetative state, though at the time Karen Quinlan was thought to be dependent on a respirator. …

Coercive Measures in Health Promotion: Can They be Justified?

Though environmental hazards and lack of medical care continue to threaten the publics health, much recent attention has turned to the role of destructive health-related behavior. If, as Fuchs suggests, changing behavior patterns is the most powerful alternative open to advanced countries in the pursuit of health, the role of the health educator is likely to grow more prominent relative to other health-care professionals. At the same time, that role may change. A campaign to solve the nations health problems by altering habits of living may require methods which are stronger than the traditional health educators efforts to facilitate and inform. This paper examines the coercive aspects of some of these possible measures and surveys the moral justifications for a policy of using coercion to bring about the desired changes in health-related behavior. Three such arguments are most plausible: that the coercion is justified by thesocial benefit; by the benefit to the coerced; and by a right of others in society to prevent the self-destructive individual from plac ing unfair burdens upon them.

Variation in the oxytocin receptor gene (OXTR) is associated with differences in moral judgment.

Moral judgments are produced through the coordinated interaction of multiple neural systems, each of which relies on a characteristic set of neurotransmitters. Genes that produce or regulate these neurotransmitters may have distinctive influences on moral judgment. Two studies examined potential genetic influences on moral judgment using dilemmas that reliably elicit competing automatic and controlled responses, generated by dissociable neural systems. Study 1 (N = 228) examined 49 common variants (SNPs) within 10 candidate genes and identified a nominal association between a polymorphism (rs237889) of the oxytocin receptor gene (OXTR) and variation in deontological vs utilitarian moral judgment (that is, judgments favoring individual rights vs the greater good). An association was likewise observed for rs1042615 of the arginine vasopressin receptor gene (AVPR1A). Study 2 (N = 322) aimed to replicate these findings using the aforementioned dilemmas as well as a new set of structurally similar medical dilemmas. Study 2 failed to replicate the association with AVPR1A, but replicated the OXTR finding using both the original and new dilemmas. Together, these findings suggest that moral judgment is influenced by variation in the oxytocin receptor gene and, more generally, that single genetic polymorphisms can have a detectable effect on complex decision processes.