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.

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.

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.

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.

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 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.

Assisted Gestation and Transgender Women.

Developments in uterus transplant put assisted gestation within meaningful range of clinical success for women with uterine infertility who want to gestate children. Should this kind of transplantation prove routine and effective for those women, would there be any morally significant reason why men or transgender women should not be eligible for the same opportunity for gestation? Getting to the point of safe and effective uterus transplantation for those parties would require a focused line of research, over and above the study of uterus transplantation for non-transgender women. Some commentators object to the idea that the state has any duty to sponsor research of this kind. They would limit all publicly-funded fertility research to sex-typical ways of having children, which they construe as the basis of reproductive rights. This objection has no force against privately-funded research, of course, and in any case not all social expenditures are responses to 'rights' properly speaking. Another possible objection raised against gestation by transgender women is that it could alter the social meaning of sexed bodies. This line of argument fails, however, to substantiate a meaningful objection to gestation by transgender women because social meanings of sexed bodies do not remain constant and because the change in this case would not elicit social effects significant enough to justify closing off gestation to transgender women as a class.

Ethical Study on the Reform and Development of Medical and Health Services in China.

At an early stage of its foundation, new China became clear about the nature of public welfare and quickly developed medical and health services, which was well received by the World Health Organization. The marketization and the reduction of input into medical and health services from the 1980s created severe adverse consequences. After the SARS' outbreak in 2003, China started to give serious consideration to its medical and health system, and to work at developing medical and health services. The new healthcare reform launched in 2009 re-emphasizes fairness and public welfare, and China's achievements have been remarkable. Of course, there are still many problems to be solved in the reform, which also paves the way for increasing the reform in future.

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.

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.

Publish or be damned: Individual Funding Requests and the publicity condition.

Many jurisdictions have processes to consider Individual Funding Requests but, with few exceptions, the decisions made with respect to these are not made public. Drawing upon Daniels and Sabin's account of the requirements of procedural justice, Accountability for Reasonableness, this paper considers several arguments for and against publishing individual funding request decisions. After briefly reviewing the case for publicity as a requirement of procedural justice and canvassing several arguments against publicity, we consider whether patient confidentiality justifies suppressing funding decisions. We claim that, with one possible exception, publication of individual funding request decisions does not raise concerns that are different in kind from those that apply to publication of legal judgments relating to healthcare, and that the protections instituted in that setting should be sufficient to allow publication of funding decisions. The discussion concludes with several cautionary notes.

What justifies the United States ban on federal funding for nonreproductive cloning?

This paper explores how current United States policies for funding nonreproductive cloning are justified and argues against that justification. I show that a common conceptual framework underlies the national prohibition on the use of public funds for cloning research, which I call the simple argument. This argument rests on two premises: that research harming human embryos is unethical and that embryos produced via fertilization are identical to those produced via cloning. In response to the simple argument, I challenge the latter premise. I demonstrate there are important ontological differences between human embryos (produced via fertilization) and clone embryos (produced via cloning). After considering the implications my argument has for the morality of publicly funding cloning for potential therapeutic purposes and potential responses to my position, I conclude that such funding is not only ethically permissible, but also humane national policy.

Clinical trials in rheumatoid arthritis: a status report from the ClinicalTrials.gov website.

The aims of this study are to describe the characteristics of clinical trials in rheumatoid arthritis (RA) listed in ClinicalTrials.gov and examine existing trends in study design, funding sources, outcomes, and drugs under investigation. We conducted a survey of ongoing clinical trials in RA registered in the ClinicalTrials.gov website. We used the advanced search option and applied the following inclusion criteria, "rheumatoid arthritis", "open studies", "interventional", and "adults 18 years or older". Of 127 eligible trials, 53.5% of the studies were either phase 3 or 4, and 40.2% were phase 1, 2, and 2/3. Two-thirds of the trials were randomized (70.9%), and over half were, in addition, double-blinded (53.5%) and placebo-controlled (53.5%). Universities were listed as the primary sponsor for 18.9% of the trials and pharmaceutical industry for 73.2%. Majority of the trials were multi-center studies (93%) conducted outside the United States (54.3%). The most frequently used endpoint was drug efficacy (54.3%) followed by drug safety (25.2%). Most industry-funded trials were open for less than 12 months, whereas most university-funded trials were open for more than 24 months (58% each). Biologic therapies were the focus of most trials in the registry (78.5%). Randomized, double-blinded, placebo-controlled, phase 3 and 4 trials form the majority of ongoing clinical trials in RA. The preponderance of industry funding of RA trials and the short duration of such trials are troubling trends which need to be addressed.

Publishing ethics in paediatric research: a cross-cultural comparative review.

The present article aims to scrutinize publishing ethics in the fields of paediatrics and paediatric nursing. Full-text readings of all original research articles in paediatrics from a high-income economy, i.e. Sweden, and from all low-income economies in Sub-Saharan Africa, were reviewed as they were indexed and stored in Web of Science for the search period from 1 January 2007 to 7 October 2009. The application of quantitative and qualitative content analysis revealed a marked discrepancy in publishing frequencies between the two contrasting economies. Authors from 16 low-income economies in Sub-Saharan Africa, with at least one article stored, were obviously closely linked to co-authorships and foreign funding sources, predominantly from Europe and the USA. Statements concerning conflicts of interest were frequently missing (both regions), even when multiple financial sources, including companies, were involved. It is necessary to be aware of possible systematic bias when using electronic databases to search for certain topics and regions. Further research regarding publishing ethics in paediatrics and paediatric nursing is emphasized.

Sliding Doors: should treatment of gender identity disorder and other body modifications be privately funded?

Gender Identity Disorder (GID) is regarded as a mental illness and included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). It will also appear in the DSM-V, due to be published in 2013. The classification of GID as a mental illness is contentious. But what would happen to sufferers if it were removed from the diagnostic manuals? Would people lose their entitlement to funded medical care, or to reimbursement under insurance schemes? On what basis should medical treatment for GID be provided? What are the moral arguments for and against funded or reimbursed medical care for GID? This paper starts out with a fiction: GID is removed from the diagnostic manuals. Then the paper splits in two, as in happened in the Howitt's 1998 film Sliding Doors. The two scenarios run parallel. In one, it is argued that GID is on a par with other body modifications, such as cosmetic and racial surgery, and that, for ethical reasons, treatment for GID should be privately negotiated by applicants and professionals and privately paid for. In the other scenario, it is argued that the comparison between GID and other body modifications is misleading. Whether or not medical treatment should be funded or reimbursed is independent of whether GID is on a par with other forms of body dissatisfaction.

Sexual rights and disability.

This paper argues against Appel's recent proposal-in this journal-that there is a fundamental human right to sexual pleasure, and that therefore the sexual pleasure of severely disabled people should be publicly funded-by thereby partially legalising prostitution. An alternative is proposed that does not need to pose a new positive human right; does not need public funding; does not need the legalisation of prostitution; and that would offer a better experience to the severely disabled: charitable non-profit organisations whose members would voluntarily and freely provide sexual pleasure to the severely disabled.