Do children get their fair share of health and dental care?

This paper reviews the work of several authors, D.W. Brock, D. Callahan, L. Churchill, L.M. Kopelman, R. Tong who consider assumptions and arguments about how to allocate health and dental care to children fairly. They use various approaches including feminist, rights based, and principled considerations, applying general notions of duty or justice to the issues of children's access to basic health and dental care. Two discuss these issues in relation to the work of David Hume. These authors consider children's greatest unmet health needs, including that of dental care, often mistakenly regarded as medically unimportant in terms of children's wellbeing, opportunities, and self-image. They review possible age bias against children in the allocation of health and dental care, the gap between what we say and do where children are concerned, and whether some fundamental shift in social thinking needs to occur.

On duties to provide basic health and dental care to children.

Children around the world suffer from poor health outcomes due to a lack of basic health and dental care, even in affluent countries. Yet duties exist to provide children these services when a society can afford to do so based on the importance of promoting (a) social utility, (b) autonomy and equality of opportunity, (c) children's well-being or best interest due to their vulnerability, and (d) compassion, sympathy, empathy and solidarity. In addition, (e) these considerations show that, in general, if competent adults should have access to federal- or state-funded health care goods, services, or benefits, then so should children. This argument has limitations; nonetheless, it can help identify systematic biases against children in federal- or state-supported health care programs and gain children access to better basic health and dental care.

Children as research subjects: a dilemma.

A complex problem exists about how to promote the best interests of children as a group through research while protecting the rights and welfare of individual research subjects. The Nuremberg Code forbids studies without consent, eliminating most children as subjects, and the Declaration of Helsinki disallows non-therapeutic research on non-consenting subjects. Both codes are unreasonably restrictive. Another approach is represented by the Council for the International Organizations of Medical Science, the U.S. Federal Research Guidelines, and many other national policies. They allow research ethics committees or institutional review boards to authorize studies with acceptable balances of likely benefits and harms, but neither clarify how to balance them nor explain the meaning of pivotal concepts, like "minimal risk." Paths to the improvement of balancing or consequentialist approaches include (1) improving standardizing of risk assessment, (2) rejecting crude utilitarianism, (3) identifying and justifying normative or moral judgments, and (4) acknowledging extra-regulatory thresholds and deontological or non-negotiable duties to children.

Help from Hume reconciling professionalism and managed care.

Health care systems are widely criticized for limiting doctors' roles as patient-advocates. Yet unrestricted advocacy can be unfairly partial, costly, and prejudicial. This essay considers three solutions to the problem of how to reconcile the demands of a just health care system for all patients, with the value of advocacy for some. Two views are considered and rejected, one supporting unlimited advocacy and another defending strict impartiality. A third view suggested by Hume's moral theory seeks to square the moral demands of professional advocacy and just health care systems. A moral basis for limited advocacy exists when it can be justified from a general or moral vantage. Consequently, ethical aspects of professionalism are not necessarily on a collision course with health care systems incorporating managed care. This solution is compatible with goals regarding the importance of humanistic education and professionalism to build patients' trust.

Values and virtues: how should they be taught?

Courses in medical ethics, bioethics, and other humanities subjects flourish in professional schools, yet a tension exists about whether their teaching goals should include trying to make students more humane and virtuous. Some hold that these courses should help instill values and virtues professed by the medical community, such as fidelity, compassion, empathy, respect, and other qualities that will make students not only better professionals but also better and more humane people. Others reject this role, arguing that humanities courses should teach students the knowledge and skills to become better problem solvers regarding theoretical, moral, and social issues; they regard it to be counterproductive, presumptuous, or futile to try to make students better persons. The author examines the extent to which these views are incompatible, arguing that a cogent philosophy of education can be neither value-free nor fully independent of moral choices. Within limits, diverse approaches to incorporating values in teaching can be a strength.

Fetal protection in Wisconsin's revised child abuse law: right goal, wrong remedy.

Authors examine Wisconsin's recent revision of its child abuse and protection laws to address substance abuse by pregnant women. The new statute enables the state to take the fetus into protective custody. Authors argue that approaching fetal protection using a child abuse model creates a series of symbolic, conceptual, and practical problems of such severity as to undermine its justifiability as a public health measure.

Bioethics and humanities: what makes us one field?

Bioethics and humanities (inclusive of medical ethics, health care ethics, environmental ethics, research ethics, philosophy and medicine, literature and medicine, and so on) seems like one field; yet colleagues come from different academic disciplines with distinct languages, methods, traditions, core curriculum and competency examinations. The author marks six related "framework" features that unite and make it one distinct field. It is a commitment to (1) work systematically on some of the momentous and well-defined sets of problems about the human condition that drive our field (such as death and dying, disability, confidentiality, professionalism, informed consent, abortion, euthanasia, assisted suicide, personhood, health-care resource allocation and environmental ethics, as well as the impact of new technologies, including genetic and reproductive); (2) use interdisciplinary approaches to unravel them; (3) employ cases and practical reasoning to understand problems and solve answers; (4) apply teaching methods and goals associated with John Dewey to make students better problem-solvers; (5) find morally justifiable solutions to the problems driving our field; and (6) seek interdisciplinary and collaborative scholarship, service or teaching.

Moral and social issues regarding pregnant women who use and abuse drugs.

Pregnant women who abuse drugs, such as alcohol, cocaine, and marihuana may face a variety of legal and social responses, including involuntary commitment, forced treatment, and criminal sanctions. These programs are intended to remedy apparent maternal-fetal conflicts but paradoxically may encourage some women to avoid beneficial medical and social services or to seek abortion. Although pregnant women have ethical duties to give due consideration to their offspring, these moral obligations fail to justify coercive and punitive programs regarding substance abuse. Coercive fetal protection policies may undermine pregnant women's trust and cooperation, violate their autonomy, weaken our civil liberties, and raise a host of ethical problems relating to race, gender, and class prejudice. Education and drug treatment programs, rather than punitive and coercive measures, may better help pregnant women fulfill their moral duties to refrain from abusing substances.

The best-interests standard as threshold, ideal, and standard of reasonableness.

The best-interests standard is a widely used ethical, legal, and social basis for policy and decision-making involving children and other incompetent persons. It is under attack, however, as self-defeating, individualistic, unknowable, vague, dangerous, and open to abuse. The author defends this standard by identifying its employment, first, as a threshold for intervention and judgment (as in child abuse and neglect rulings), second, as an ideal to establish policies or prima facie duties, and, third, as a standard of reasonableness. Criticisms of the best-interests standard are reconsidered after clarifying these different meanings.

Ethical assumptions and ambiguities in the Americans With Disabilities Act.

The Americans With Disabilities Act (ADA) promotes social justice by protecting disabled persons from discrimination and prejudice. It seeks equality of opportunity for them and protects their well being by giving them fair access to goods, services and benefits. These rights are circumscribed in the ADA, however, by constraints of cost, efficiency, utility, and certain social mores. The ADA offers little direction about how to set priorities when these values come into conflict, or about whether equality or opportunity favors equivalent or preferential treatment for disadvantaged people. Until these ambiguities and potential value conflicts are resolved, a central moral and social problem remains unresolved: How can we demonstrate commitment to the rights and welfare of those with severe disabilities while placing fair limits upon their claims? Five special concerns are discussed: (1) eligibility and the allocation of health care; (2) the meaning of 'qualified but disabled' in employing people with mental disabilities; (3) equal opportunity and problems of envy and malingering; (4) ADA accommodation and public protection through testing and licensure; and (5) ADA protection and problems of backlash. Rather than simply wait to see what courts and administrative agencies decide, we should evaluate the moral conflicts, articulate criteria, and help make some difficult choices on morally defensible grounds.

Informed consent for genetic research on stored tissue samples.

OBJECTIVE: To develop recommendations for obtaining adequate informed consent in the future when gathering tissue samples that may be used for genetic studies and defining the circumstances under which it is necessary to obtain further consent if tissue samples already in hand are to be used for such research. PARTICIPANTS: Scientists, ethicists, lawyers, and consumers selected by the National Center for Human Genome Research and the Centers for Disease Control and Prevention to represent a wide array of opinions. EVIDENCE: Statutes, regulations, and cases and articles on law and ethics. CONSENSUS PROCESS: Initial workshop, followed by circulation of several drafts of this document with opportunities for comment by workshop participants and others as well as smaller meetings involving participants with widely differing views. CONCLUSION: Genetic research using stored tissue samples poses an array of benefits and risks to individuals, researchers, and society. As a result, the workshop participants conclude that (1) informed consent is required for all genetic research using linkable samples unless conditions for limitation or waiver are met; (2) informed consent is not required for genetic research using anonymous samples but may be considered if identifiers are to be removed from currently linkable samples; (3) institutional review boards could usefully review all protocols that propose to use samples for genetic research; and (4) further work regarding these issues is warranted.

Philosophy and medical education.

The most effective way to integrate philosophy into medical education uses ethical, social, and conceptual problems arising in medical practice such as those about informed consent, confidentiality, competency, resource allocation, the doctor-patient relationship, and death and dying. Medical students become better physicians by learning salient views on these matters and by developing philosophical skills and attitudes to (1) examine key assumptions; (2) broaden their perspectives and gain self-knowledge; (3) develop critical thinking skills about the kind of judgments they make, how bias affects their views, and the scope and limits of their knowledge claims; (4) generate tolerance, openness, and skepticism about dogma; and (5) cultivate empathy. Learning these skills and dispositions using moral, conceptual, and social issues facing them will enable students to recognize these issues when they arise in their medical practices and learn how to respond to them in justifiable ways. It will also strengthen the health care profession and institutions overall by fostering the openness, the questioning mind, and the critical thinking essential to the practice of good medicine.

Conceptual and moral disputes about futile and useful treatments.

A series of cases have crystallized disputes about when medical treatments are useful or futile, and consequently about the doctor-patient relationship, resource allocation, communication, empathy, relief of suffering, autonomy, undertreatment, overtreatment, paternalism and palliative care. It is helpful to understand that utility and futility are complimentary concepts and that judgments about whether treatments are useful or futile in the contested cases have common features. They are: (1) grounded in medical science, (2) value laden, (3) at or near the threshold of utility, and (4) burdensome. No schema for line-drawing escapes borderline cases and we should focus upon justification of the empirical, ethical and evaluative components underlying these judgments, rather than make an arbitrary decision about whether doctors, patients or societal consensus should be the final arbiter.