Just health care (II): Is equality too much?

In a previous essay I criticized Engelhardt's libertarian conception of justice, which grounds the view that society's obligation to assure access to adequate health care for all is a matter of beneficence [1]. Beneficence fails to capture the moral stringency associated with many claims for access to health care. In the present paper I argue that these claims are really matters of justice proper, where justice is conceived along moderate egalitarian lines, such as those suggested by Rawls and Daniels, rather than strong egalitarian lines. Further, given the empirical complexity associated with the distribution of contemporary health care, I argue that what we really need to address the relevant policy issues adequately is a theory of health care justice, as opposed to an all-purpose conception of justice. Daniels has made an important start toward that goal, though there are some large policy areas which I discuss that his account of health care justice does not really speak to. Finally, practical matters of health care justice really need to be addressed in a ‘non-ideal’ mode, a framework in which philosophers have done little.     

Measured fairness, situated justice: feminist reflections on health care rationing

Bioethical discussion of justice in health care has been much enlivened in recent years by new developments in the theory of rationing and by the emergence of a strong communitarian voice. Unfortunately, these developments have not enjoyed much in the way of close engagement with feminist-inspired reflections on power, privilege, and justice. I hope here to promote interchange between "mainstream" treatments of justice in health care and feminist thought.     

Does Confucian Ethics Integrate Care Ethics and Justice Ethics? The Case of Mencius

In recent years, scholars of Confucian ethics have debated on important issues such as whether Confucian ethics embraces, or should embrace, universal values and impartiality. Some have argued that Confucian ethics integrates both care and justice, and that Confucian ethics is both particularistic and universalistic. In this essay, I will defend a view of the relation between care and justice and the relation between care ethics and justice ethics on the basis of the notion of ‘configuration of values,’ and show why care ethics and justice ethics cannot be integrated. I will support this view by a reading of some pertinent passages in the Mencius.     

Using Systems of Care to Reduce Incarceration of Youth with Serious Mental Illness

Youth with serious mental illness come into contact with juvenile justice more than 3 times as often as other youth, obliging communities to expend substantial resources on adjudicating and incarcerating many who, with proper treatment, could remain in the community for a fraction of the cost. Incarceration is relatively ineffective at remediating behaviors associated with untreated serious mental illness and may worsen some youths' symptoms and long-term prognoses. Systems of care represent a useful model for creating systems change to reduce incarceration of these youth. This paper identifies the systemic factors that contribute to the inappropriate incarceration of youth with serious mental illness, including those who have committed non-violent offenses or were detained due to lack of available treatment. It describes the progress of on-going efforts to address this problem including wraparound and diversion programs and others utilizing elements of systems of care. The utility of systems of care principles for increasing access to community-based mental health care for youth with serious mental illness is illustrated and a number of recommendations for developing collaborations with juvenile justice to further reduce the inappropriate incarceration of these youth are offered.     

Ethics in Long-Term Care: Are the Principles Different?

It has become common in medical ethics to discuss difficult cases in terms of the principles of respect for autonomy, beneficence, nonmaleficence, and justice. These moral concepts or principles serve as maxims that are suggestive of appropriate clinical behavior. Because this language evolved primarily in the acute care setting, I consider whether it is in need of supplementation in order to be useful in the long-term care setting. Through analysis of two typical cases involving residents of long-term care facilities, I argue for the additional principles of candor and responsibility for narrative integrity.     

Should basic care get priority? Doubts about rationing the Oregon way

Recognition of the need to ration care has focused attention on the concept of "basic care." It is often thought that care that is "basic" is also morally prior. This article questions that premise in light of the usual definitions of "basic." Specifically, it argues that Oregon's rationing scheme, which defines "basic" in terms of cost-effective care, fails to pay sufficient attention to important ethical principles such as justice.     

In the world but not of it: managing the conflict between Christian and institution.

Christian physicians, nurses and other health care workers must manage a daily conflict of conscience between their Christian faith and predominantly secular health care institutions. This essay examines various efforts for managing these conflicts: a turn towards social justice or a seeking of holiness. Seeking social justice, however, is theologically empty. Traditionally, the Christian requirement that we be "in this world but not of it" requires a journey along a narrow path to holiness. Christian medical morality must, therefore, be understood within this light. However, just as there cannot be generic health care, but rather health care for a particular person's needs and problems there cannot be generic holiness, but only a holiness grounded in worshiping God rightly. In so worshiping the Christian will be assisted in negotiating the inescapable and perilous vocation of being in the world but not of it.     

论丹尼尔斯医疗保健公正理论

诺曼·丹尼尔斯将罗尔斯的正义理论应用到医疗资源分配公正领域,他的理论认为医疗保健的道德重要性就在于它保护正常的功能从而保护机会,平等机会不仅提供医疗保健权利的基础,它也帮助我们确定这个权利的承诺限度。此外我们应该依靠公平的程序达到医疗保健公正的分配。     

Can organizational justice mitigate the negative effects of shift work and fixed-term employment?

The present study examined whether organizational justice moderates the association of shift work and employment type with patient-related stress, stress symptoms, and musculoskeletal symptoms. Cross-sectional survey data from 1270 Finnish female elderly care staff aged 18–69 years was used. Analyses of covariance were used to examine the associations adjusted for age,marital status, education, and tenure. Organizational justice was associated with lower levels of patient-related stress, stress symptoms, and musculoskeletal symptoms. Organizational justice mitigated stress symptoms related to working night shift and three shifts. In addition, organizational justice mitigated the patient-related stress associated with working on fixed-term contracts. Organizational justice was also able to alleviate musculoskeletal symptoms associated with working on permanent contracts. Thus, we found evidence for organizational justice being able to mitigate the negative effects of shift work and employment type. Promoting organizational justice in organizations with shift work and lots of fixed-term contracts is of importance.     

Gender bias and moral decision making: The moral orientations of justice and care

This study investigated gender related moral reasoning in student essays containing arguments on moral issues. Undergraduate students in a medical ethics course viewed two films on morally controversial issues. The students wrote brief essays about the films which were transcribed and numerically coded to conceal the author's gender from the evaluator. Using a coding scheme originated by Lyons, the evaluator classified each essay as a justice/right essay or a care/response essay or an equal response essay. Subsequently, calculations were made to determine the percentage of male authored essays that were justice/rights essays or care/response essays and the percentage of female authored essays that were justice/rights or care/response essays. The males (87.7%) tended to exhibit the justice/rights moral orientation, and the females (69.4%) exhibited the care/response moral orientation. Several different calculations were made to determine various degrees of gender related orientations also. The difference in orientation was highly statistically significant (p≤0.001). These data contribute to understanding moral orientation and development. Interpretations are given to explain some differences between the genders and help explain the traditional roles in society that males and females have played historically.     

Care and Justice in Real-Life Moral Reasoning

Moral reasoning of 57 (Time 1) and 59 (Time 2) nursing, social-work and law-enforcement students was investigated in terms of care and justice reasoning about hypothetical and real-life dilemmas. The analysis methods were the Ethic of Care Interview, the Moral Judgment Interview, Lyons' Moral Orientation Scheme and Wark and Krebs' classification of real-life dilemmas. The type of dilemma predicted moral orientation usage. Prosocial dilemmas pulled for care and antisocial dilemmas for justice orientation. Level of justice reasoning varied according to the type of dilemma. Real-life care reasoning was consistent with participants' competence, with the exception of transgression-type dilemmas at Time 2. Levels of care and justice reasoning were highly correlated with each other. These results underscore the importance of the dilemma type and suggest that care reasoning is a significant part of real life morality. The study recommends the ECI as a new model to account for real-life care reasoning.     

Taking care of one's own: justice and family caregiving

This paper asks whether adult children have aduty of justice to act as caregivers for theirfrail, elderly parents. I begin (Sections I.and II.) by locating the historical reasons whyrelationships within families were not thoughtto raise issues of justice. I argue that thesereasons are misguided. The paper next presentsspecific examples showing the relevance ofjustice to family relationships. I point outthat in the United States today, the burden ofcaregiving for dependent parents fallsdisproportionately on women (Sections III. andIV.). The paper goes on to use Rawls'theoretical tool of the veil of ignorance toargue that caring for parents should not belinked to a person's sex and more generally,that there is no duty of justice to assume therole of caregiver for dependent parents(Sections V.). Although justice does notprovide the moral foundations for parent care,I show that it nonetheless places importantlimits on the instinct to care. I concludethat the voice of justice should be audible,and is intrinsically present, withinfamilies.     

Gender differences in moral orientation: a meta-analysis

C. Gilligan's (1982) critique of L. Kohlberg's theory of moral reasoning and her assertion that two modes of moral reasoning (justice and care) exist have been the subject of debate within the field of psychology for more than 15 years. This meta-analysis was conducted to review quantitatively the work on gender differences in moral orientation. The meta-analysis revealed small differences in the care orientation favoring females (d = -.28) and small differences in the justice orientation favoring males (d = .19). Together, the moderator variables accounted for 16% of the variance in the effect sizes for care reasoning and 17% of the variance in the effect sizes for justice reasoning. These findings do not offer strong support for the claim that the care orientation is used predominantly by women and that the justice orientation is used predominantly by men.     

The Significance of the Concept of Disease for Justice in Health Care

In this paper, I want to scrutinise the value of utilising the concept of disease for a theory of distributive justice in health care. Although many people believe that the presence of a disease-related condition is a prerequisite of a justified claim on health care resources, the impact of the philosophical debate on the concept of disease is still relatively minor. This is surprising, because how we conceive of disease determines the amount of justified claims on health care resources. Therefore, the severity of scarcity depends on our interpretation of the concept of disease. I want to defend a specific combination of a theory of disease with a theory of distributive justice. A naturalist account of disease, together with sufficientarianism, is able to perform a gate-keeping function regarding entitlements to medical treatment. Although this combination cannot solve all problems of justice in health care, it may inform rationing decisions as well.     

Gratuity,Embodiment, and Reciprocity

Protestant Christian ethicist Timothy Jackson and secular feminist philosopher Eva Feder Kittay each explore the relationship between love or care and justice through the lens of human dependency. Jackson sharply prioritizes agape over justice, whereas Kittay articulates a more complex and integrated understanding of the relationship of care and distributive justice. An account of Christian love and its relation to justice must account for the gratuity, mutuality, and reciprocity that pervade human existence. Such an account must integrate provision for another's basic needs, a feature of agape, with a distributive justice that fairly allocates the material prerequisites of care and the burden of caring labor. Kittay's treatment of care and justice is more adequate to the realities of human embodiment and the social organization of care than Jackson's, but neither offers a fully adequate ground for the moral personhood of all human beings, including deeply dependent persons.     

Integrating justice and care in animal ethics

In this paper I argue that the standoff between justice and care approaches to animal ethics presents us with a false dilemma. We should take justice's focus on reasoning from principles, and care's use of sympathetic awareness, as two integrated deliberative capacities necessary for the consideration of arguments for extending moral concern to animals. Such an integrated approach rests on a plausible account of the psychology of moral deliberation. I develop my argument as follows. Section I summarizes the nature of the debate between justice and care approaches to animal ethics, focusing on Brian Luke's arguments against justice approaches. Section II provides pro-justice rebuttals to Luke's objections. These rebuttals, while largely successful against Luke's objections, do not account for the intuition that sympathy does play a central epistemological role in animal ethics. Section III explains how sympathy cognitively simulates the perspective of the other, and thus can play an epistemological role in animal ethics. I argue that the abilities to simulate the perspective of the other and to reason from moral principles can complement each other. In section IV, I argue that though it may not be desirable to use both sympathy and reasoning from principles in all moral deliberation, it is a desirable aim when offering, and considering, moral arguments for what I will term the "extensionist project" of extending over moral concern to animals. I make this idea plausible by elucidating the claim that arguments for this project are best thought of as second-order deliberations about our first-order deliberative life.     

Care and Justice Moral Orientation: A Scale for Its Assessment

A quantitative measure of adult moral orientation, based on the theoretical frameworks of Kohlberg and Gilligan, was developed to measure preference for "justice" or "care"-oriented moral thinking. The Moral Orientation Scale Using Childhood Dilemmas (MOS), a short, objective measure, presents adults with a series of dilemmas frequently faced by children, each followed by two care-oriented and two justice-oriented responses to the dilemma. The procedures for developing and scoring the measure are discussed, and validity and reliability data are presented. Used with both male and female social work and law students, as expected, the MOS shows males to be more justice-oriented in their moral reasoning than females who are shown to be more care-oriented. Moreover, in further agreement with Gilligan's theory that gender and experience, taken together, are related to moral reasoning style, male lawyers and female social workers are shown to have the strongest preferences.     

Justice: The Neglected Argument and the Pregnant Vision

Countering the present trend in the discourse on justice wherein human reason is perceived and marginalized as an embarrassment to justice and the trend to reject the concept of formal justice, this paper argues that there is formal justice and the essence of justice is setting things right and setting righteousness to stand straight. By this token, justice means the rule of reason, not the rule of power and desire, and the ethics of justice differs fundamentally from the ethics of care/benevolence. The popular assumption that justice as the rule of reason is incompatible with the idea of justice as accommodating diversity is unjustified. The paper joins the present discourse on justice from a historical perspective. It examines the historical Confucian and neo-Confucian concept of justice in a way of its dialogues with other Western concepts of justice such as Plato's concept of justice.     

Judaism, justice, and access to health care

This paper develops the traditional Jewish understanding of justice (tzedakah) and support for the needy, especially as related to the provision of medical care. After an examination of justice in the Hebrew Bible, the values and institutions of tzedakah in Rabbinic Judaism are explored, with a focus on legal codes and enforceable obligations. A standard of societal responsibility to provide for the basic needs of all, with a special obligation to save lives, emerges. A Jewish view of justice in access to health care is developed on the basis of this general standard, as well as explicit discussion in legal sources. Society is responsible for the securing of access to all health care needed by any individual. Elucidation of this standard of need and corresponding societal obligations, and the significance of the Jewish model for the contemporary United States, are considered.     

Acceptance, avoidance, and ambiguity: conflicting social values about childhood disability

Advances in medical technology now permit children who need ventilator assistance to live at home rather than in hospitals or institutions. What does this ventilator-dependent life mean to children and their families? The impetus for this essay comes from a study of the moral experience of 12 Canadian families--parents, ventilator-dependent child, and well siblings. These families express great love for their children, take on enormous responsibilities for care, live with uncertainty, and attempt to create "normal" home environments. Nevertheless, they experience social isolation, sometimes even from their extended families and health care providers. Their lives are constrained in many ways. The challenges faced by parents of technology-dependent children raise questions of justice within society and within families.