Emerging Dental Specialties and Ethics.

This paper discusses ethical dimensions related to the formal recognition of emerging dental specialties. It explores several issues related to the potential emergence of several new dental specialty areas. There are good reasons that dentistry should open the door to these new specialties, and patients would benefit. The ethical considerations for and against formal acceptance are examined.

Enhancement and Obsolescence: Avoiding an "Enhanced Rat Race".

A claim about continuing technological progress plays an essential, if unacknowledged, role in the philosophical literature on "human enhancement." I argue that-should it eventuate-continuous improvement in enhancement technologies may prove more bane than benefit. A rapid increase in the power of available enhancements would mean that each cohort of enhanced individuals will find itself in danger of being outcompeted by the next in competition for important social goods-a situation I characterize as an "enhanced rat race." Rather than risk the chance of being rendered technologically and socially obsolete by the time one is in one's early 20s, it may be rational to prefer that a wide range of enhancements that would generate positional disadvantages that outweigh their absolute advantages be prohibited altogether. The danger of an enhanced rat race therefore constitutes a novel argument in favor of abandoning the pursuit of certain sorts of enhancements.

Medical responsibility.

These comments seek to take issue with the contention that society has a responsibility to provide its members with any needed health care. In order to deal with this claim we must first make clear exactly what it meant by the proposition. I take it that those who embrace this view mean considerably more than that each of us has a moral obligation to contribute to those in need of medical attention who are unable, for one reason or another, to afford the necessary care. This is a moral proposition and is traditionally dealt with under the heading of charity. But the contention, as here used, means considerably more since its main implications are not moral but primarily political.

Market-based reforms in health care are both practical and morally sound.

In this paper I argue that the free-market provision of health care is both practical and morally sound, and is superior in both respects to its provision by the State. The State provision of health care will be inefficient compared to its free-market alternative. It will thus provide less health care to persons for the same amount of expenditure, and so save fewer lives and alleviate less suffering for two reasons: state actors have no incentive to husband their resources effectively, and that in a non-market setting, special interest groups can capture resources through lobbying, perverting them away from their efficient allocation. Given these considerations of efficiency a utilitarian should morally prefer the free-market provision of health care to its State-based rival. Furthermore, even if one is not a utilitarian, the free-market provision of health care will be more morally sound than its State-based alternative because it will likely better respect the autonomy of persons, and will better refrain from imposing values upon persons. With these points in hand, I address two prominent objections to a free market system of health care.

Justice and fairness: a critical element in U.S. health system reform.

The case for U.S. health system reform aimed at achieving wider insurance coverage in the population and disciplining the growth of costs is fundamentally a moral case, grounded in two principles: (1) a principle of social justice, the Just Sharing of the costs of illness, and (2) a related principle of fairness, the Prevention of Free-Riding. These principles generate an argument for universal access to basic care when applied to two existing facts: the phenomenon of "market failure" in health insurance and, in the U.S., the existing legal guarantee of access to emergency care. The principles are widely shared in U.S. moral culture by conservatives and liberals alike. Similarly, across the political spectrum, the fact of market failure is not contested (though it is sometimes ignored), and the guarantee of access to emergency care is rarely challenged. The conclusion generated by the principles is not only that insurance for a basic minimum of care should be mandatory but that the scope of that care should be lean, efficient, and constrained in its cost.

Medicine: business or profession?

As professionals, doctors have a contractual relationship with society that trains them and confers on them exclusive power to practice medical care. In the contract, power and responsibility should be balanced. When the power is conferred by society to a profession, the profession should take responsibility for society, including the provision of high quality services, and maintain high standard principled conduct and integrity.

Eliminating drug price differentials across government programmes in the USA.

Federal agencies in the USA pay significantly different prices for the same prescription drugs because each agency uses a different approach to derive the payment rate. Because we do not identify any economic rationale or socially accepted moral reasoning that would justify the current level of price variation, we suggest that the federal government should pay a uniform price for each drug. Laws and regulations that give certain federal agencies the ability to earn rebates, use formularies, or permit other special arrangements would need to be eliminated in order to have a single payment rate. This could make some government agencies worse off than others; however, a uniform payment rate would not need to affect beneficiaries' current financial contributions, access to drugs, benefits or overall public expenditures. At the same time, having a single rate would permit the government to adopt a more effective approach to purchasing drugs and send a consistent message to pharmaceutical companies concerning which types of drugs the government wants them to develop for government beneficiaries. How this single price would be derived and how it would compare with the lowest or highest prices currently achieved by government agencies would depend on a variety of policy issues including the government's desire to encourage pharmaceutical research and development and the need to control health care spending.

[Competition in healthcare--a health systems' perspective]. / Wettbewerb im Gesundheitswesen--eine Gesundheitssystemperspektive.

That "more competition in healthcare primarily produces more needs-based equity, better quality, higher efficiency, reduced costs and less bureaucracy" is a familiar claim. But is it correct? Three types of competition can be identified within a triangle: (1) competition among third-party-payers for insured individuals/customers, (2) competition among providers for patients, and (3) competition among third-party payers for contracts with providers--and vice versa. German and international evidence for these three types of competition demonstrates that many expectations--e.g., that patients can be steered based on quality information--are wishful thinking. Instead of market and competition, regulation is needed (e.g., in the form of an effective risk-based allocation mechanism) to ensure high-quality care for those 5% of the population incurring 50% of the healthcare expenditures (i.e., the seriously ill patients), while at the same time competition based on selective contracts does not pay off for the majority of the population due to high transaction costs.

"Efforts to Reprioritise the Agenda" in China: British American Tobacco's Efforts to Influence Public Policy on Secondhand Smoke in China.

BACKGROUND: Each year, 540 million Chinese are exposed to secondhand smoke (SHS), resulting in more than 100,000 deaths. Smoke-free policies have been demonstrated to decrease overall cigarette consumption, encourage smokers to quit, and protect the health of nonsmokers. However, restrictions on smoking in China remain limited and ineffective. Internal tobacco industry documents show that transnational tobacco companies (TTCs) have pursued a multifaceted strategy for undermining the adoption of restrictions on smoking in many countries. METHODS AND FINDINGS: To understand company activities in China related to SHS, we analyzed British American Tobacco's (BAT's) internal corporate documents produced in response to litigation against the major cigarette manufacturers to understand company activities in China related to SHS. BAT has carried out an extensive strategy to undermine the health policy agenda on SHS in China by attempting to divert public attention from SHS issues towards liver disease prevention, pushing the so-called "resocialisation of smoking" accommodation principles, and providing "training" for industry, public officials, and the media based on BAT's corporate agenda that SHS is an insignificant contributor to the larger issue of air pollution. CONCLUSIONS: The public health community in China should be aware of the tactics previously used by TTCs, including efforts by the tobacco industry to co-opt prominent Chinese benevolent organizations, when seeking to enact stronger restrictions on smoking in public places.

[From service of charity to profit center? An ethical critique of commodification of medicine]. / Vom karitativen Dienst am Menschen zum Profitcenter? Zu den ethischen Grenzen der Marktorientierung in der Medizin.

This paper wants to reflect the actual transformations of modern medicine. The implementation of the market into medicine is only possible by presupposing at least three implications: (a) the patient as consumer, (b) medical care as commodity, (c) competitiveness as criteria for good medicine. All three implications seem to be inadequate if the core identity of medicine is considered. If medicine is regarded as a human service for suffering people, it becomes clear that what medicine has to offer must be more than mere commodity. It is suggested to see medicine as a social institution which is linked to the obligation of the whole society to give medicine the possibility and the economic independence in order to remain an institution of charity which assures help for every man in need and which cannot be reduced to a mere enterprise.