Leslie P. Francis

Some Animals Are More Equal Than Others

It is a welcome development when academic philosophy starts to concern itself with practical issues, in such a way as to influence peoples lives. Recently this has happened with one moral issue in particular—but infortunately it is the wrong issue, and peoples actions have been influenced in the wrong way. The issue is that of the moral status and treatment of animals. A number of philosophers have argued for what they call ‘animal liberation’, comparing it directly with egalitarian causes such as womens liberation and racial equality and suggesting that, if racism and sexism are rationally indefensible, so is ‘speciesism’. If one ought to give equal consideration to the interests of all human beings, then, so they daim, one must on the same grounds and in the same way recognize that ‘all animals are equal’, be they human or non-human. We believe that this assimilation of ‘animal liberation’ to human liberation movements is mistaken.

Ethics, Pandemics, and the Duty to Treat

Numerous grounds have been offered for the view that healthcare workers have a duty to treat, including expressed consent, implied consent, special training, reciprocity (also called the social contract view), and professional oaths and codes. Quite often, however, these grounds are simply asserted without being adequately defended or without the defenses being critically evaluated. This essay aims to help remedy that problem by providing a critical examination of the strengths and weaknesses of each of these five grounds for asserting that healthcare workers have a duty to treat, especially as that duty would arise in the context of an infectious disease pandemic. Ultimately, it argues that none of the defenses is currently sufficient to ground the kind of duty that would be needed in a pandemic. It concludes by sketching some practical recommendations in that regard.

Justice through Trust: Disability and the “Outlier Problem” in Social Contract Theory*

Viewed as a bargain among equals for reciprocal advantage, social contract theory has been criticized as ignoring outliers such as persons with disabilities. Critics such as Martha Nussbaum have contended that the idea of a social contract must be abandoned in favor of other ways of modeling justice. This article contends that the problem lies in modeling social contract justifications as bargaining for mutual advantage. The insight of social contract theory rests on the importance of respect for individuals with differing conceptions of their good. Reconceptualizing contract theory in terms of building trust relationships fosters inclusiveness and respect.

The Blackwell guide to medical ethics

Notes on Contributors. Introduction: Rosamond Rhodes (Mount Sinai School of Medicine), Leslie P. Francis (University of Utah) and Anita Silvers (San Francisco State University). Part I: Individual Decisions About Clinical Issues. I.1: Patient Decisions. 1. Autonomy, the Good Life and Controversial Choices: Julian Savulescu (University of Oxford). 2. Individual Responsibility and Reproduction: Rachel A. Ankeny (University of Sydney). 3. Patient and Family Decisions about Life-Extension and Death: Felicia Nimue Ackerman (Brown University). I.2: Individual Decisions of Physicians and Other Health Care Professionals. 4. The Professional Responsibilities of Medicine: Rosamond Rhodes (Mount Sinai School of Medicine). 5. Truth telling: Roger Higgs (Emeritus, Kings College, London). 6. Medical Confidentiality: Kenneth Kipnis (University of Hawaii at Manoa). 7. Patient Competence and Surrogate Decision-Making: Dan W. Brock (Harvard Medical School). 8. Ending Life: F.M. Kamm (Harvard University). 9. Discrimination in Medical Practice: Justice and the Obligations of Health Care Providers to Disadvantaged Patients: Leslie P. Francis (University of Utah). 10. Institutional Practices, Ethics, and the Physician: Mary V. Rorty (Stanford University), Ann E. Mills (University of Virginia), and Patricia H. Werhane (DePaul University). Part II: Legislative and Judicial Decisions About Social Policy. II.2: Liberty. 11. Reproductive Choice: Rebecca Bennett (University of Manchester) and John Harris (University of Manchester). 12. Public Policy and Ending Lives: Evert van Leeuwen (Vrije Universiteit Medisch Centrum), and Gerrit Kimsma (Vrije Universiteit Medisch Centrum). 13. Drug Legalization: Douglas N. Husak (Rutgers University). 14. Selling Organs, Gametes, and Surrogacy Services: Janet Radcliffe Richards (University College, London). 15. The Patient as Victim and Vector: The Challenge of Infectious Disease for Bioethics: Margaret P. Battin (University of Utah), Leslie P. Francis (University of Utah), Jay A. Jacobson (University of Utah), Charles B. Smith (Emeritus, University of Utah). 16. Uses of Science in Medical Ethics: Glenn McGee (Albany Medical College) and Dyrleif Bjarnadottir. 11.2: Justice. 17. Allocation of Scarce Resources: Paul Menzel (Pacific Lutheran University). 18. Just Caring: The Challenges of Priority-Setting in Public Health: Leonard M. Fleck (Michigan State University). 19. Justice and the Financing of Health Care: Stephen R. Latham (Quinnipiac University). 20. Judgment and Justice: Evaluating Health Care for Chronically Ill and Disabled Patients: Anita Silvers (San Francisco State University). 21. Justice in Research on Human Subjects: David R. Buchanan (National Cancer Institute, Bethesda), and Franklin G. Miller (National Institutes of Health, Bethesda). 22. Ethics of Disclosure Following a Medical Injury: Time for Reform?: Troyen Anthony Brennan (Emeritus, Harvard Medical School). 23. Pre-existing Conditions: Genetic Testing, Causation and the Justice of Medical Insurance: Robert T. Pennock (Michigan State University). Index

The Physician-Patient Relationship and a National Health Information Network

The growing use of interoperable electronic health records is likely to have significant effects on the physician-patient relationship. This relationship involves two-way trust: of the physician in patients, and of the patients in their providers. Interoperable records opens up this relationship to further view, with consequences that may both enhance and undermine trust. On the one hand, physicians may learn (from additional records) that information from their patients is - or is not - to be trusted. On the other hand, patients may learn from the increased oversight made possible by electronic records that their trust in their physicians is - or is not - warranted. Release of information through new methods of surveillance may also undermine patient trust. The article concludes that because trust is fragile, attention to transparency and confidentiality in the use of interoperable electronic records is essential.

Competitive Sports, Disability, and Problems of Justice in Sports

A “level playing field” is a stock metaphor for equality. Despite its status as a near-cliché, however, the metaphor has been given limited theoretical attention. Deliberately tilting the field so that one set of contestants must consistently run uphill while their opponents get a downhill ride is perhaps a clear violation of the metaphor. But what of a bumpy field, where luck frequently plays a role in how the ball bounces, to play on another metaphor? Such a field is not “level” in the most obvious sense, but it may afford all contestants an equal chance, unless the bumps are concentrated on one side of the field and the contestants do not switch sides in an appropriately balanced way. But note this last qualification: If the bumps are concentrated around one goal, and it is an advantage to be attacking that goal at the end of the game, the field may not be level at all. And what of a field that is designed to fit some characteristics of players better than other characteristics? For example, a basketball court with baskets at different heights would play quite differently from a court where all baskets are 12 feet high. A soccer pitch with smaller goals would perhaps reward goalies with different physical endowments than the goal as it is presently shaped. These questions about the relationship between players and playing fields reach to the heart of how we understand sports, disability, and equality itself. These issues are the subject of this special section.

Let Them In: Family Presence during Intensive Care Unit Procedures

Families have for decades advocated for full access to intensive care units (ICUs) and meaningful partnership with clinicians, resulting in gradual improvements in family access and collaboration with ICU clinicians. Despite such advances, family members in adult ICUs are still commonly asked to leave the patients room during invasive bedside procedures, regardless of whether the patient would prefer family to be present. Physicians may be resistant to having family members at the bedside due to concerns about trainee education, medicolegal implications, possible effects on the technical quality of procedures due to distractions, and procedural sterility. Limited evidence from parallel settings does not support these concerns. Family presence during ICU procedures, when the patient and family member both desire it, fulfills the mandates of patient-centered care. We anticipate that such inclusion will increase family engagement, improve patient and family satisfaction, and may, on the basis of studies of open visitation, pediatric ICU experience, and family presence during cardiopulmonary resuscitation, decrease psychological distress in patients and family members. We believe these goals can be achieved without compromising the quality of patient care, increasing provider burden significantly, or increasing risks of litigation. In this article, we weigh current evidence, consider historical objections to family presence at ICU procedures, and report our clinical experience with the practice. An outline for implementing family procedural presence in the ICU is also presented.

Concerns About Justification for Fetal Genome Sequencing

only among parents but also among providers. Many parents have reported that providers have given them outdated and overly negative portrayals of how their child’s life would be affected by a genetic condition (Nelson Goff et al. 2013), and these reports likely stem from known limitations on the genetic education of typical prenatal providers and on their ability (due to billing and patient load) to research and properly counsel patients about a huge array of rare genetic conditions.

Rights Variation within a Federalist System: Understanding the Importance of Mobility

Cosmopolitanism at the international level—the recognition of an international human rights regime—has been much defended of late. Little attention has been paid, however, to the federalist analogue: should there be insistence on a national rights regime? Or should variation in the recognition of rights be tolerated at the subnational level, as a necessary concession to moral disagreement, as an effort to contain problematic experiments, or as a way to generate progress about rights? This article argues that subnational variation in the recognition of rights represents a second-best solution to the problem of deep moral disagreement about rights. However, federalism provides a second-best solution only on the condition that citizens are able to move from one subnational jurisdiction to another. To the extent that citizens are able to move to rights regimes that are more favorable to them, intranational variation in the recognition of rights may have advantages over international variation, where national borders may pose barriers to migration. However, in the United States, despite the privileges and immunities of national citizenship, there remain impressive legal barriers to such mobility in the case of contested rights. Given these barriers, federalism as it exists in the United States today does not fully realize the advantages of a second-best solution to deep moral disagreements about rights.

Genomic knowledge sharing: A review of the ethical and legal issues

The importance of genomic information for care of individual patients and for the development of knowledge about treatment efficacy is becoming increasingly apparent. This information is probabilistic and involves the use of large data sets to increase the likelihood of detecting low frequency events. Duties and rights of patients with respect to this information have been much discussed, including informed consent to the use of individual information, privacy and confidentiality, rights to know or not to know, and individual ownership of information about themselves. But this is only one side of the information equation. On the other side of the equation are duties of information holders: malpractice and duties to warn, responsibilities of data stewardship, intellectual property and ownership, reciprocity, and justice. This article argues that if we take duties of patients to share information seriously, we must also consider duties on the part of information holders about how they protect and use information.