Publicly Funded Health Care for Pregnant Undocumented Immigrants: Achieving Moral Progress Through Overlapping Consensus.

What just societies owe to non-citizen immigrants is a controversial question. This paper considers three accounts of the requirements of distributive justice for non-citizens to determine what they might suggest about the provision of publicly funded health care to pregnant undocumented immigrants. These accounts are compared to locate an overlapping consensus on the duty of the state to provide care to pregnant undocumented immigrants. The aim of this paper is not to take a substantive position on the "right" prenatal policy, but rather to explore the moral space that this issue occupies and suggest that real moral progress can be achieved through the consistent application of shared values.

The moral perils of conditional cash transfer programmes and their significance for policy: a meta-ethnography of the ethical debate.

Conditional cash transfer (CCT) is a compelling policy alternative for reducing poverty and improving health, and its effectiveness is promising. CCT programmes have been widely deployed across geographical, economic and political contexts, but not without contestation. Critics argue that CCTs may result in infringements on freedom and dignity, gender discrimination and disempowerment and power imbalances between programme providers and beneficiaries. In this analysis, we aim to identify the ethical concepts applicable to CCTs and to contextualize these by mapping the tensions of the debate, allowing us to understand the separate contributions as parts of a larger whole. We searched a range of databases for records on public health CCT. Strategies were last run in January 2017. We included 31 dialectical articles deliberating the ethics of CCTs and applied a meta-ethnographic approach. We identified 22 distinct ethical concepts. By analysing and mapping the tensions in the discourse, the following four strands of debate emerged: (1) responsibility for poverty and health: personal vs public duty, (2) power balance: autonomy vs paternalism, (3) social justice: empowerment vs oppression and (4) marketization of human behaviour and health: 'fair trade' vs moral corruption. The debate shed light on the ethical ideals, principles and doctrines underpinning CCT. These were consistent with a market-oriented liberal welfare regime ideal: privatization of public responsibilities; a selective rather than a universal approach; empowerment by individual entrepreneurship; marketization of health with a conception of human beings as utility maximizing creatures; and limited acknowledgement of the role of structural injustices in poverty and health. Identification of key tensions in the public health ethics debate may expose underpinning ideological logics of health and social programmes that may be at odds with public values and contemporary political priorities. Decisions about CCTs should therefore not be considered a technical exercise, but a context-dependent process requiring transparent, informed and deliberative decision-making.

Scientists' political behaviors are not driven by individual-level government benefits.

Is it appropriate for scientists to engage in political advocacy? Some political critics of scientists argue that scientists have become partisan political actors with self-serving financial agendas. However, most scientists strongly reject this view. While social scientists have explored the effects of science politicization on public trust in science, little empirical work directly examines the drivers of scientists' interest in and willingness to engage in political advocacy. Using a natural experiment involving the U.S. National Science Foundation Graduate Research Fellowship (NSF-GRF), we causally estimate for the first time whether scientists who have received federal science funding are more likely to engage in both science-related and non-science-related political behaviors. Comparing otherwise similar individuals who received or did not receive NSF support, we find that scientists' preferences for political advocacy are not shaped by receiving government benefits. Government funding did not impact scientists' support of the 2017 March for Science nor did it shape the likelihood that scientists donated to either Republican or Democratic political groups. Our results offer empirical evidence that scientists' political behaviors are not motivated by self-serving financial agendas. They also highlight the limited capacity of even generous government support programs to increase civic participation by their beneficiaries.

Prenatal Care for Undocumented Immigrants: Professional Norms, Ethical Tensions, and Practical Workarounds.

This paper examines the practice implications of various state policies that provide publicly funded prenatal care to undocumented immigrants for health care workers who see undocumented patients. Data were collected through in-depth interviews with purposively sampled health care workers at safety net clinics in California, Maryland, Nebraska, and New York. Health care workers were asked about the process through which undocumented patients receive prenatal care in their health center and the ethical tensions and frustrations they encounter when providing or facilitating this care under policy restrictions. Respondents discussed several professional practice norms as well as the ethical tensions they encountered when policy or institutional constraints prevented them from living up to professional norms. Using Nancy Berlinger's "workarounds" framework, this paper examines health care workers' responses to the misalignment of their professional norms and the policy restrictions in their state. These findings suggest that the prenatal policies in each state raise ethical and professional challenges for the health care workers who implement them.

Subsidizing PGD: The Moral Case for Funding Genetic Selection.

Preimplantation genetic diagnosis (PGD) allows the detection of genetic abnormalities in embryos produced through in vitro fertilization (IVF). Current funding models in Australia provide governmental subsidies for couples undergoing IVF, but do not extend to PGD. There are strong reasons for publicly funding PGD that follow from the moral principles of autonomy, beneficence and justice for both parents and children. We examine the objections to our proposal, specifically concerns regarding designer babies and the harm of disabled individuals, and show why these are substantially outweighed by arguments for subsidizing PGD. We argue that an acceptance of PGD is aligned with present attitudes towards procreative decision making and IVF use, and that it should therefore receive government funding.

Appeal to the Rule of Rescue in health care: discriminating and not benevolent?

Thirty years of debate have passed since the term "Rule of Rescue" has been introduced into medical ethics. Its main focus was on whether or why medical treatment for acute conditions should have priority over preventive measures irrespective of opportunity costs. Recent contributions, taking account of the widespread reluctance to accept purely efficiency-oriented prioritization approaches, advance another objection: Prioritizing treatment, they hold, discriminates against statistical lives. The reference to opportunity costs has also been renewed in a distinctly ethical fashion: It has been stipulated that favoring help for identifiable lives amounts to a lack of benevolence for one's fellow creatures. The present article argues against both objections. It suggests that the debate's focus on consequences (deaths or severe ill health) should be reoriented by asking which aspects of such states of affairs are actually attributable to a decision maker who judges within a specific situation of choice.

Is infertility a disease and does it matter?

Claims about whether or not infertility is a disease are sometimes invoked to defend or criticize the provision of state-funded treatment for infertility. In this paper, I suggest that this strategy is problematic. By exploring infertility through key approaches to disease in the philosophy of medicine, I show that there are deep theoretical disagreements regarding what subtypes of infertility qualify as diseases. Given that infertility's disease status remains unclear, one cannot uncontroversially justify or undermine its claim to medical treatment by claiming that it is or is not a disease. Instead of focusing on disease status, a preferable strategy to approach the debate about state-funded treatment is to explicitly address the specific ethical considerations raised by infertility. I show how this alternative strategy can be supported by a recent theoretical framework in the philosophy of medicine which avoids the problems associated with the concepts of health and disease.

Obligation and the Changing Nature of Publicly Funded Healthcare.

This article explores the relationship between obligation and publicly funded healthcare. Taking the National Health Service (NHS) as the focal point of discussion, the article presents a historical analysis of the shifting nature and function of obligation as it relates to this institution. Specifically, and drawing inspiration from recent literature that takes seriously the notion of the tie or bond at the core of obligation, the article explores how the forms of social relation and bonds underpinning a system like the NHS have shifted across time. This is undertaken via an analysis of Aneurin Bevan's vision of the NHS at its foundation, the importance today of the patient (and the individual generally) within publicly funded healthcare, and the role of contract as a contemporary governance mechanism within the NHS. A core feature of the article is its emphasis on the impact that a variety of economic factors-including privatisation, marketisation, and the role of debt and finance capital-are having on previously settled understandings of obligation and the forms of social relation underpinning them associated with the NHS. It is therefore argued that an adequate analysis of obligation in healthcare law and related fields must extend beyond the doctor-patient relationship and that of state-citizen of the classical welfare state in order to incorporate new forms of relation, such as that between creditor and debtor, and new actors, including private healthcare providers and financial institutions.

Should Gender Reassignment Surgery be Publicly Funded?

Transgender people have among the highest rates of suicide attempts of any group in society, driven strongly by the perception that they do not belong in the sex of their physical body. Gender reassignment surgery (GRS) is a procedure that can change the transgender person's physical body to accord with their gender identity. The procedure raises important ethical and distributive justice concerns, given the controversy of whether it is a cosmetic or medical procedure and the economic costs associated with performing the procedure. This paper argues that there is a strong case for funding GRS as a matter of clinical necessity and justice. This paper will be divided in four key sections: First, the state of transgender health will be outlined, including the role of GRS and common objections to it. Second, a number of common objections to GRS will be analysed at the outset and shown to be unconvincing. Third, a constructive argument will be advanced, arguing that publicly funded GRS is clinically necessary, cost-effective, and demanded by principles of justice. Fourth, the paper will briefly discuss moralistic biases and why we demand a higher burden of justification for funding GRS compared with other analogous procedures.

Endangerment of the iPSC stock project in Japan: on the ethics of public funding policies.

We examined the ethical justification for a national policy governing public funding for the induced pluripotent stem cell (iPSC) stock project in Japan and argue that the initiation of the iPSC stock project in 2012, when no clinical trial using iPSC-derived products had yet succeeded, was premature and unethical. Our analysis considers a generally accepted justice criterion and shows it fails to justify public funding of the iPSC stock project. We also raise concerns related to the massive amounts of public funding at stake and the absence of evidence supporting claimed success rates. We conclude that the iPSC stock project should be re-considered and deferred until a substantial number of clinical trials using iPSC-derived products are deemed successful. This analysis should benefit others worldwide as they consider their own public funding policies.

[The Rule of Rescue - Irrational and Discriminating?] / Rule of Rescue vs. Rettung statistischer Leben.

State of the debate: The "Rule of Rescue" refers to the practice that, in order to save people from immediate peril, societies incur high costs largely irrespective of the fact that many more lives could be saved under alternative uses of the resources. The practice has been found difficult to explain, let alone justify, and has often been criticized. In the early literature in the context of the Oregon rationing experiment, the irrationality objection dominated in view of the obvious lack to consider opportunity costs. More recent contributions, taking account of the declining support for purely efficiency-oriented prioritization approaches, advance an equity objection: The practice discriminates against statistical lives. Intent of the present contribution: This article provides a critical assessment of both objections. Results: The following contentions result from the analysis: 1. The equity objection is unfounded; 2. Following the rule of rescue is (in a certain sense) inefficient, but it is not irrational; 3. The criticized judgments result from deep-seated shortcomings in the action-theoretical concepts used (or rather, omitted) in the literature. These shortcomings are inherent in the consequentialist framework dominating the debate and deserve more attention.

Which strings attached: ethical considerations for selecting appropriate conditionalities in conditional cash transfer programmes.

Conditional cash transfers (CCTs) present a promising approach to simultaneously tackle chronic poverty and poor health. While these programmes clearly embody beneficent aims, questions remain regarding the ethical design of CCTs. Limited guidance exists for the ethical evaluation of the defining feature of these programmes: the conditionalities. Drawing upon prominent public health ethics frameworks and social justice theories, this paper outlines five categories of morally relevant considerations that CCT programme designers should consider when assessing which behaviours or outcomes they select as conditionalities for payment: (1) likelihood of yielding desired health outcomes, (2) risks and burdens, (3) receptivity, (4) attainability and (5) indirect impacts and externalities. When evaluating potential conditionalities across these five categories of considerations, it is important to recognise that not all beneficiaries or subgroups of beneficiaries will fare equally on each. Given that most CCTs aim to reduce inequities and promote long-term health and prosperity for the most disadvantaged, it is critical to apply these considerations with due attention to how different segments of the beneficiary population will be differentially affected. Taken on balance, with due reflection on distributional effects, these five categories represent a comprehensive set of considerations for the moral analysis of specific conditionalities and will help ensure that CCT designers structure programmes in a way that is both morally sound and effective in achieving their goals.

The elephant in the room: ethical issues associated with rare and expensive medical conditions.

The treatment of rare and expensive medical conditions is one of the defining qualities of paediatric cardiology and congenital heart surgery. Increasing concerns over healthcare resource allocation are challenging the merits of treating more expensive forms of congenital heart disease, and this trend will almost certainly continue. In this manuscript, the problems of resource allocation for rare and expensive medical conditions are described from philosophical and economic perspectives. The argument is made that current economic models are limited in the ability to assess the value of treating expensive and rare forms of congenital heart disease. Further, multi-disciplinary approaches are necessary to best determine the merits of treating a patient population such as those with significant congenital heart disease that sometimes requires enormous healthcare resources.

The commercialization of university-based research: Balancing risks and benefits.

BACKGROUND: The increasing push to commercialize university research has emerged as a significant science policy challenge. While the socio-economic benefits of increased and rapid research commercialization are often emphasized in policy statements and discussions, there is less mention or discussion of potential risks. In this paper, we highlight such potential risks and call for a more balanced assessment of the commercialization ethos and trends. DISCUSSION: There is growing evidence that the pressure to commercialize is directly or indirectly associated with adverse impacts on the research environment, science hype, premature implementation or translation of research results, loss of public trust in the university research enterprise, research policy conflicts and confusion, and damage to the long-term contributions of university research. The growing emphasis on commercialization of university research may be exerting unfounded pressure on researchers and misrepresenting scientific research realities, prospects and outcomes. While more research is needed to verify the potential risks outlined in this paper, policy discussions should, at a minimum, acknowledge them.

Obligations of low income countries in ensuring equity in global health financing.

BACKGROUND: Despite common recognition of joint responsibility for global health by all countries particularly to ensure justice in global health, current discussions of countries' obligations for global health largely ignore obligations of developing countries. This is especially the case with regards to obligations relating to health financing. Bearing in mind that it is not possible to achieve justice in global health without achieving equity in health financing at both domestic and global levels, our aim is to show how fulfilling the obligation we propose will make it easy to achieve equity in health financing at both domestic and international levels. DISCUSSION: Achieving equity in global health financing is a crucial step towards achieving justice in global health. Our general view is that current discussions on global health equity largely ignore obligations of Low Income Country (LIC) governments and we recommend that these obligations should be mainstreamed in current discussions. While we recognise that various obligations need to be fulfilled in order to ultimately achieve justice in global health, for lack of space we prioritise obligations for health financing. Basing on the evidence that in most LICs health is not given priority in annual budget allocations, we propose that LIC governments should bear an obligation to allocate a certain minimum percent of their annual domestic budget resources to health, while they await external resources to supplement domestic ones. We recommend and demonstrate a mechanism for coordinating this obligation so that if the resulting obligations are fulfilled by both LIC and HIC governments it will be easy to achieve equity in global health financing. Although achieving justice in global health will depend on fulfillment of different categories of obligations, ensuring inter- and intra-country equity in health financing is pivotal. This can be achieved by requiring all LIC governments to allocate a certain optimal per cent of their domestic budget resources to health while they await external resources to top up in order to cover the whole cost of the minimum health opportunities for LIC citizens.