James Dwyer

Illegal immigrants health care and social responsibility.

In this paper I want to focus on the situation of illegal immigrants. I will discuss several different answers to the question about what ethical responsibility we have to provide health care to illegal immigrants. (I shall simply assume that societies have an ethical obligation to provide their own citizens with a reasonably comprehensive package of health benefits.) The answers that I shall discuss tend to conceptualize the ethical issues in terms of individual desert professional ethics or human rights. I want to discuss the limitations of each of these approaches and to offer an alternative. I shall approach the issues in terms of social responsibility and discuss the moral relevance of work. In doing so I tend to pull bioethics in the direction of social ethics and political philosophy. Thats the direction I think it should be heading. But before I begin the ethical discussion I need to say more about the phenomenon of illegal immigration. (excerpt)

What's wrong with the global migration of health care professionals? Individual rights and international justice.

When health care workers migrate from poor countries to rich countries, they are exercising an important human right and helping rich countries fulfill obligations of social justice. They are also, however, creating problems of social justice in the countries they leave. Solving these problems requires balancing social needs against individual rights and studying the relationship of social justice to international justice.

Teaching global bioethics.

We live in a world with enormous disparities in health. The life expectancy in Japan is 80 years; in Malawi, 40 years. The under-five mortality in Norway is 4/1000; in Sierra Leone, 316/1000. The situation is actually worse than these figures suggest because average rates tend to mask inequalities within a country. Several presidents of the IAB have urged bioethicists to attend to global disparities and to broaden the scope of bioethics. For the last six years I have tried to do just that. In this paper, I report and reflect on my attempts to teach bioethics in ways that address global health and justice. I then discuss ways to address key ethical issues in global health: the problem of inequalities; the nature of the duty to assist; the importance of the duty not to harm; the difference between a cosmopolitan and a political view of justice. I also discuss how teaching about global health may help to shift the emphasis in bioethics--from sensational cases to everyday matters, from autonomy and justice, and from access to healthcare to the social determinants of health. At the end of my paper, I reflect on questions that I have not resolved: how to delineate the scope of bioethics, whether my approach over-politicises bioethics, and how to understand the responsibilities of bioethicists.

How to Connect Bioethics and Environmental Ethics: Health, Sustainability, and Justice

In this paper, I explore one way to bring bioethics and environmental ethics closer together. I focus on a question at the interface of health, sustainability, and justice: How well does a society promote health with the use of no more than a just share of environmental capacity? To address this question, I propose and discuss a mode of assessment that combines a measurement of population health, an estimate of environmental sustainability, and an assumption about what constitutes a fair or just share. This mode of assessment provides an estimate of the just and sustainable life expectancy of a population. It could be used to monitor how well a particular society promotes health within just environmental limits. It could also serve as a source of information that stakeholders use when they deliberate about programs, policies, and technologies. The purpose of this work is to focus attention on an ethical task: the need to fashion institutions and forms of life that promote health in ways that recognize the claims of sustainability and justice.

THE DIFFICULT PATIENT

The term difficult patient refers to a group of patients with whom a physician may have trouble forming a normal therapeutic relationship. The care of these patients can present many ethical dilemmas, ranging from issues of patient autonomy to questions of appropriate use of resources, which the emergency physician must be prepared to handle. Encounters with these patients also challenge physicians to explore and cultivate many of the character traits and virtues necessary to being a humane, caring, and ethical practitioner.

Rethinking Transplantation between Siblings

Parents and physicians often subject ill children to treatments that have inherent risks. The basic justification for placing these children at risk is the reasonable expectation that they will benefit. But sometimes parents and physicians place healthy children at risk for the benefit of other children. This happens when children serve as kidney donors or bone marrow donors for their siblings. Our purpose in this paper is to criticize the standard way of thinking about these cases and to suggest an alternative. In cases of transplantation between siblings, we believe that the standard approach misconstrues the nature of the ethical problem, ignores the ethical import of family relationships, and requires an egocentric evaluation of the situation. We shall try to offer an alternative way of thinking about these cases, a way that takes seriously the ethical aspect of relationships. But before we formulate an alternative, we want to examine the standard approach. The Standard Approach The standard approach to questions about placing persons at risk is based on a ranking of the following ideas: (1) informed consent, (2) substituted judgment, and (3) best interests. In this approach informed consent is viewed as the first and best justification. Patients are to be informed about all reasonable alternatives, the expected benefits, and the significant risks; they can then decide, based on their values and attitudes, whether the benefits of a proposed treatment are worth the risks. Thus the practice of informed consent is meant to protect patients against unwanted intrusions and to give expression to the idea of patient autonomy. The practice of informed consent is meant to apply only to those who have the requisite decisional capacity. Children, or at least young children, lack the requisite ability to understand and appreciate risks and benefits and so are viewed as incompetent to give valid consent. Although the understanding that is needed may be specific to the proposed treatment, and the degree of understanding may be relative to the risk-benefit ratio of the proposed treatment, it seems clear that young children are not competent to consent to tissue transplantation. So the transplantations must be justified in terms other than the informed consent of these children. In the standard approach the next line of justification is in terms of substituted judgment, an attempt to decide in the given circumstances as the incompetent person would if he or she were competent. Thus a substituted judgment is really a conditional judgment: if the person were competent, then he or she would decide such and such. The application of this doctrine to the case of children is quite problematic. Young children are not formerly competent adults who have lost their capacity to decide. They are young people who have never been competent, and may not have well-formed values and outlooks. Thus it is not even clear what it would mean to decide as the young child would if the child were competent. When it is not possible to use the notion of substituted judgment because the person was never competent (or because not enough is known about the preferences of the person who was once competent to yield a determinate answer), then the conventional approach turns to the idea of the persons best interests. Simply put, on the best interests standard the agent decides to do what is best for the person. Thus, on the conventional approach, the justification for placing a young child at risk must be in terms of that childs best interests. Tissue transplantation between young children must then be shown to be in the recipients and the donors best interests. Some transplantation programs have taken the standard approach a step further by requiring that an impartial child advocate be appointed for the donor.[1] Of course, when cases are disputed in court, a guardian ad litem is appointed and charged with representing the childs interests. …

Developing the duty to treat: HIV, SARS, and the next epidemic

SARS, like HIV, placed healthcare workers at risk and raised issues about the duty to treat. But philosophical accounts of the duty to treat that were developed in the context of HIV did not adequately address some of the ethical issues raised by SARS. Since the next epidemic may be more like SARS than HIV, it is important to illuminate these issues. In this paper, we sketch a general account of the duty to treat that arose in response to HIV. Our purpose is not to defend or criticise this account, but to show that it needs to be developed in order to address three important issues. The first issue concerns how risks should be distributed among healthcare professionals. The second issue concerns the conflicts that arise between professional duties and family duties. The third issue concerns the forms of support that societies owe healthcare workers during epidemics. Our descriptions of these issues are drawn from our experience of the SARS epidemic in Taiwan.

The disasters of March 11th

On March 11, 2011, one of the most powerful earthquakes ever recorded occurred off the northeast coast of Japan. It destroyed buildings, damaged infrastructure, and killed people in the Tohoku region. The associated tsunami was even more destructive, engulfing coastal areas and obliterating whole towns. The earthquake and the tsunami together occasioned a third disaster: the meltdown at the Fukushima nuclear power plant. Like most people, Dr. Makoto Sato was horrified by the destruction and suffering that he saw. He wanted to help and felt that he should, but doing something appropriate and effective was not easy. He is a general internist and bioethicist at a university medical center in Hokkaido, the large island north of Tohoku. What should Dr. Sato have done then? What should he do now? Language: en

Climate Change and Ethical Change

This chapter approaches a crucial ethical question: How should we respond to climate change? To begin, I sketch some of the impacts that climate change will have on human health. Then I consider who will be most vulnerable to these impacts. People’s vulnerability will depend on their temporal position, geographical location, social position, and on qualities of the society in which they live. Since some people and generations are more vulnerable to the risks of climate change, while other people and generations contribute more to the problem, climate change raises deep issues about justice. After noting why and where issues of justice arise, I focus attention on ethical issues about responsiveness, responsibility, and ethical change. I consider how people who are differently situated should respond to the current situation. Many people, especially in countries with high emissions, need to change the way they live: the technologies that they use, the social practices and institutions they participate in, and the habits and virtues that they embody. These are some of the social, political, and ethical changes that climate change calls for.

One world: the ethics of globalization

Behind much of the discussion about globalization is a deep ethical concern. People are rightly worried about the impact of globalization on human wellbeing and the natural environment. And people who work in public health are especially worried about its impact on the health of those who are least advantaged, who often have the shortest life expectancies and the greatest burden of disease. In his new book, Peter Singer examines some of the ethical issues involved. He devotes one chapter to climate change, first summarizing, in a very concise and fair way, the scientific evidence on global warming. He then notes some of the probable consequences: sea levels will rise and inundate areas of human habitation; weather patterns will become more volatile; food production will fall at some latitudes, though it may rise at others; and tropical diseases will spread. Rich nations will be better able than poor nations to deal with these changes. At present, Americans emit about 5 tonnes of carbon per person, while Chinese emit 0.76, and Indians 0.29. Singer finds no ethical justification for the present system that allows some people to emit a large share of the greenhouse gases, and others to bear more of the costs. So he asks what a fair distribution would be. He argues in favour of allocating ‘‘equal per capita future entitlements to a share of the capacity of the atmospheric sink.’’ In the chapter devoted to economic globalization, Singer poses questions about environmental protection, national sovereignty, democratic practices, and the well-being of the poorest people in the world. Then he sorts through the evidence to answer these questions. Although World Trade Organization (WTO) rules allow member countries to take measures to protect human health and the natural environment, WTO practices often invoke a ‘‘product-versusprocess’’ distinction that has the effect of limiting themeasures that members can adopt. Singer finds that the use of this argument tends to devalue environmental protection, national sovereignty, and democratic control. How has economic globalization affected the poorest people in the world? Singer considers the effect on both inequality in relative terms and wellbeing in absolute terms. He reviews the methods people have used to assess inequality, measure poverty, and determine causality. His conclusion is sceptical: without better data on household incomes, we cannot knowwhat the overall impact has been. Since the Second World War, a kind of legal globalization has been taking place. Ideas about human rights, crimes against humanity, and international courts have begun to limit the old idea of national sovereignty. We have come to see that there must be ethical and legal limits to what nations can do, even to their own citizens. In a chapter entitled ‘‘One Law,’’ Singer focuses attention on this development and tries to specify guidelines for military interventions for humanitarian reasons. When do outsiders have a right and a responsibility to intervene? Singer believes that humanitarian intervention ‘‘is justified when it is a response (with reasonable expectations of success) to acts that kill or inflict serious bodily or mental harm on large numbers of people,’’ though of course this answer raises further questions. One of the most interesting parts of this book is his discussion of foreign aid. Singer has lectured and written about this issue for over 30 years. During this time, he has changed some of the policies he advocates, but he has not changed his ethical view: when we can help people in great need without sacrificing something of comparable moral worth, we have a moral duty to do so. Not to help in such circumstances is wrong. Singer sees no reason for assigning much moral weight to national boundaries. Although he recognizes impartial reasons for giving some preference to family members and close friends, he argues that the strong preference we often give to fellow citizens is unjustified, especially when we consider the pressing needs of the 1.2 billion people living in poverty. He thinks that wealthy countries are morally required to give more aid to low-income countries. And he thinks ‘‘that anyone who has enough money to spend on the luxuries and frivolities so common in affluent societies should give at least 1 cent in every dollar of their income to those who have trouble getting enough to eat, clean water to drink, shelter from the elements, and basic health care.’’ There are points where I disagreed with Singer, but my disagreements are more about emphasis than policy. I would place more emphasis on the importance of face-to-face communities. Families, neighbourhoods, and local associations are settings in which people develop dispositions that are vital for ethical life and civil society. I realize that local associations can also foster hatred, racism, and indifference, but I’m concerned that social changes are disrupting the good as well as the bad. We need to combine caring local communities with ideals of global justice. More than Singer does, I would emphasize two important roles for moral philosophers. The first, in which Singer excels, is formulating, analysing, and evaluating ethical arguments. In doing this, he very usefully exposes confusions and double standards. But there is a second role: good philosophy can capture its time in thought, interpreting historical change in ways that show what is at stake. Others can then make practical use of that interpretation as they strive to fashion a more just and liveable world. n