A Bioethics for Democracy: Restoring Civic Vision.

Democracy-as a form of governance, a moral community, and a way of life-is under great stress. The prospects for democracy and bioethics are linked because bioethics relies on an open society and a democratic cultural environment in order to flourish. For its part, democracy can be restored and strengthened by widespread cultural and psychological support for the values of mutual recognition, equal dignity and respect for persons, and solidarity, interdependence, and the common good. Promoting values such as these is in keeping with the founding vision of bioethics, which was a civic vision. At the present time, bioethics can and should continue to be a bioethics for democracy by engaging directly in civic learning and civic place-making. These have a significant impact on health as well as on democracy.

Ethics codes and reflective practice in public health.

In public health, acting ethically and fulfilling obligations to the public requires careful reflection and intentional decision making. This article discusses the role that an ethics code in public health can play in providing both an educational tool and a behavioral standard. It argues that maintaining public trust requires that public health personnel to live up to standards of professionalism in their conduct, and in order to do so they must have the capabilities necessary to cope in an ethically reflective manner with the pressures and decisions they face. The article illustrates this perspective by discussing the public health ethics code revision process currently underway in the USA.

Relational Ethics for Public Health: Interpreting Solidarity and Care.

This article defends 'relational theorizing' in bioethics and public health ethics and describes its importance. It then offers an interpretation of solidarity and care understood as normatively patterned and psychologically and socially structured modes of relationality; in a word, solidarity and care understood as 'practices.' Solidarity is characterized as affirming the moral standing of others and their membership in a community of equal dignity and respect. Care is characterized as paying attention to the moral (and mortal) being of others and their needs, suffering, and vulnerability. The wager of relational theorizing in health care and public health is that substantive ethical visions of solidarity and care will provide support for more just and egalitarian health care and public health policies.

Solidarity and care as relational practices.

Many working in bioethics today are engaging in forms of normative interpretation concerning the meaningful contexts of relational agency and institutional structures of power. Using the framework of relational bioethics, this article focuses on two significant social practices that are significant for health policy and public health: the practices of solidarity and the practices of care. The main argument is that the affirming recognition of, and caring attention paid to, persons as moral subjects can politically motivate a society in three respects. The recognition of solidarity and the attention of care can prompt progressive change toward a democratic willingness: (a) to provide for equal respect for rights and dignity; (b) to provide the social resources and services needed for just health and well-being; and (c) to focus its creativity and wealth on the actualization of potential flourishing of each and all. Solidarity is discussed as a morally developmental stance that moves from standing up for another, standing up with another, and standing up as another. Care is discussed as a morally developmental stance that moves from the attentive rehabilitation of another, attentive companionship with and for another, and attentive commitment to another.

Reconceptualizing Autonomy: A Relational Turn in Bioethics.

History's judgment on the success of bioethics will not depend solely on the conceptual creativity and innovation in the field at the level of ethical and political theory, but this intellectual work is not insignificant. One important new development is what I shall refer to as the relational turn in bioethics. This development represents a renewed emphasis on the ideographic approach, which interprets the meaning of right and wrong in human actions as they are inscribed in social and cultural practices and in structures of lived meaning and interdependence; in an ideographic approach, the task of bioethics is to bring practice into theory, not the other way around. The relational turn in bioethics may profoundly affect the critical questions that the field asks and the ethical guidance it offers society, politics, and policy. The relational turn provides a way of correcting the excessive atomism of many individualistic perspectives that have been, and continue to be, influential in bioethics. Nonetheless, I would argue that most of the work reflecting the relational turn remains distinctively liberal in its respect for the ethical significance of the human individual. It moves away from individualism, but not from the value of individuality.In this review essay, I shall focus on how the relational turn has manifested itself in work on core concepts in bioethics, especially liberty and autonomy. Following a general review, I conclude with a brief consideration of two important recent books in this area: Jennifer Nedelsky's Law's Relations and Rachel Haliburton's Autonomy and the Situated Self.

Can evidence drive health equity in the COVID-19 pandemic and beyond?

Using scoping review methods, we systematically searched multiple online databases for publications in the first year of the pandemic that proposed pragmatic population or health system-level solutions to health inequities. We found 77 publications with proposed solutions to pandemic-related health inequities. Most were commentaries, letters, or editorials from the USA, offering untested solutions, and no robust evidence on effectiveness. Some of the proposed solutions could unintentionally exacerbate health inequities. We call on health policymakers to co-create, co-design, and co-produce equity-focussed, evidence-based interventions with communities, focussing on those most at risk to protect the population as a whole. Epidemiologists collaborating with people from other relevant disciplines may provide methodological expertise for these processes. As epidemiologists, we must interrogate our own methods to avoid propagating any unscientific biases we may hold. Epidemiology must be used to address, and never exacerbate, health inequities-in the pandemic and beyond.

Health care costs in end-of-life and palliative care: the quest for ethical reform.

Health reform in the United States must address both access to medical services and universal insurance coverage, as well as health care cost containment. Uncontrolled health care costs will undermine improvements in access and coverage in the long-run, and will also be detrimental to other important social programs and goals. Accordingly, the authors offer an ethical perspective on health care cost control in the context of end-of-life and palliative care, an area considered by many to be a principal candidate for cost containment. However, the policy and ethical challenges may be more difficult in end-of-life care than in other areas of medicine. Here we discuss barriers to developing high quality, cost effective, and beneficial end-of-life care, and barriers to maintaining a system of decision making that respects the wishes and values of dying patients, their families, and caregivers. The authors also consider improvements in present policy and practice-such as increased timely access and referral to hospice and palliative care; improved organizational incentives and cultural attitudes to reduce the use of ineffective treatments; and improved communication among health professionals, patients, and families in the end-of-life care planning and decision-making process.

John Rawls, Godfather of Bioethics.

At a time when ethical and political philosophy were thought passé, John Rawls gave serious attention to ethical questions, providing them with a renewed academic legitimacy. This helped fields of practical ethics such as bioethics become established in higher education and in public affairs. This essay addresses the influence Rawls has had on bioethics through both the style and the substance of his ethical argumentation. The essay argues that his distinctive rhetorical strategy and tone attempted to rein in the scope of normative commitments in order to make an equilibrium between refined understandings of freedom and equality possible and sustainable. Bioethics has been strongly influenced by this approach to maintaining social stability in a liberal society that has become highly stratified and culturally diverse. Bioethics continues to echo the Rawlsian call for a calmly reasoned political life but finds that call increasingly difficult to answer.

Redoing the Demos.

Forces including extreme economic inequality, cultural polarization, and the monetizing and privatizing of persons as commodities are undermining the forms of moral recognition and mutuality upon which democratic practices and institutions depend. These underlying factors, together with more direct modes of political corruption, manipulation, and authoritarian nationalism, are undoing Western democracies. This essay identifies and explores some vital underpinnings of democratic citizenship and civic learning that remain open to revitalization and repair. Building care structures and practices from the ground up and developing inclusive and egalitarian modes of solidarity in a pluralistic society are the focus of discussion. The essay argues that solidarity and care are essential relationships and practices of moral recognition upon which democratic political agency and freedom rest. The social-relational lifeworld and the democratic lifeworld are interdependent. Democratic citizenship is itself a relational practice that supports other practices. Democratic governance properly carried out fosters an underlying social solidarity and care and in turn draws moral and political legitimacy upward from them.

A Gay Epidemiologist and the DC Commission of Public Health AIDS Advisory Committee.

Based upon the lead author's deep personal and professional experience, this case narrative illustrates the importance of engagement between public health practitioners and members of affected populations and their advocates. The case underscores the need to build strong coalitions to address serious public health and social issues. It also illustrates how decisions about control groups in research raise ethical issues. In addition, the case illustrates the reality that public health and social services are sometimes inadequate in the face of dire circumstances. Justice in public health has both a distributive aspect (how to allocate limited resources and distribute potential benefits as fairly as possible) and a procedural dimension (ensuring public participation, especially of those most affected). Frameworks for public health ethics, which post-date the events detailed in the autobiographical case narrative, highlight both distributive justice and procedural justice.

Civic Learning for a Democracy in Crisis.

This essay introduces a special report from The Hastings Center entitled Democracy in Crisis: Civic Learning and the Reconstruction of Common Purpose, which grew out of a project supported by the John S. and James L. Knight Foundation. This multiauthored report offers wide-ranging assessments of increasing polarization and partisanship in American government and politics, and it proposes constructive responses to this in the provision of objective information, institutional reforms in government and the electoral system, and a reexamination of cultural and political values needed if democracy is to function well in a pluralistic and diverse society. The essays in the special report explore the norms of civic learning and institutions, social movements, and communal innovations that can revitalize civic learning in practice. This introductory essay defines and explains the notion of civic learning, which is a lynchpin connecting many of the essays in the report. Civic learning pertains to the ways in which citizens learn about collective social problems and make decisions about them that reflect the duties and responsibilities of citizenship. Such learning can occur in many social settings in everyday life, and it can also be facilitated through participation in the processes of democratic governance on many levels. Civic learning is not doctrinaire and is compatible with a range of public goals and policies. It is an activity that increases what might be called the democratic capability of a people.

Recommendations for Better Civic Learning: Building and Rebuilding Democracy.

This is the concluding essay for a special report from The Hastings Center entitled Democracy in Crisis: Civic Learning and the Reconstruction of Common Purpose, which grew out of a project supported by the John S. and James L. Knight Foundation. This essay provides an integrative discussion of various theoretical and practical reform perspectives offered by other essays in the report. It also offers a number of recommendations. It notes that the aim of the special report is not to propose specific reform measures but, rather, to consider larger, more theoretic concerns related to political and economic questions, which are personal and structural-psychological, cultural, and institutional-at the same time. In response, this essay argues that the best relationship between the citizenry and government in a democracy is not one of deference, nor one of contestation, but one that is critically constructive, which in turn is linked to practices of civic learning. To be constructive, citizens need scientific literacy, an understanding of how government and other institutions work, critical thinking abilities, and many open and diverse forums for civic learning to offset the increasingly isolating media "bubbles" that are the only source of information for many. The essay then formulates five recommendations designed to facilitate critically constructive citizenship and civic learning. These are creating a basis for civic participation, acquiring information, talking to each other, designing institutional change, and achieving deliberation.

Remembering Hospice.

This book review essay discusses The Crisis of US Hospice Care: Family and Freedom at the End of Life (2019), by Harold Braswell.

Daniel Callahan and the Vocation of Bioethics.

Did Dan Callahan know the calling he was displaying in his own work and offering to others in the special intellectual garden of The Hastings Center, which he cocreated, with Will Gaylin, and went on to prune and tend for nearly four decades? I would say, yes, he knew what he was about. Successful people usually have self-confidence and drive in abundance, but in Dan's case, there was something more profound and interesting at work. Having gone through the endnotes of his latest book one day, I asked him how he found time to read so widely. He said he had learned to be an efficient skimmer who could pull out the nuggets he valued from another's work because he had a few magnetic ideas from which he would brook no distraction.

The ethics of using quality improvement methods in health care.

Quality improvement (QI) activities can improve health care but must be conducted ethically. The Hastings Center convened leaders and scholars to address ethical requirements for QI and their relationship to regulations protecting human subjects of research. The group defined QI as systematic, data-guided activities designed to bring about immediate improvements in health care delivery in particular settings and concluded that QI is an intrinsic part of normal health care operations. Both clinicians and patients have an ethical responsibility to participate in QI, provided that it complies with specified ethical requirements. Most QI activities are not human subjects research and should not undergo review by an institutional review board; rather, appropriately calibrated supervision of QI activities should be part of professional supervision of clinical practice. The group formulated a framework that would use key characteristics of a project and its context to categorize it as QI, human subjects research, or both, with the potential of a customized institutional review board process for the overlap category. The group recommended a period of innovation and evaluation to refine the framework for ethical conduct of QI and to integrate that framework into clinical practice.