In private journals published after his death, writer and critic Alfred Kazin confesses that his weakness as a scholar has been to dwell on the “high points,” the emotional peak of a text rather than the argument. He reflects, “But only the argument settles anything.”
In this issue of CQ’s annual open forum, authors expand arguments in questions of justice, health policy, research ethics, and clinical decisionmaking. This continues the forum’s tradition of serving as an intellectual marketplace, a space where controversial ideas are offered for debate. Rather than consensus, the aim is to seek common ground through reflective thought and critical conversation.
We begin with a topic that has been neglected in medical ethics: the factors that influence the ascription of intentions. As pointed out by Lynn Jansen, Jessica Fogel, and Mark Brubaker in their article, “Experimental Philosophy, Clinical Intentions, and Evaluative Judgment,” self-reporting of clinical intentions has been commonly taken at face value. Drawing on recent work in experimental philosophy, the authors describe a study that provides support to the position that physicians’ ascription of intentions to clinical actors is influenced by their prior evaluative judgments of the conduct in question. These findings could be important for improving the self-understanding of clinical decisionmaking. And, on the assumption that clinical intentions do make an ethical difference to clinical conduct, they ultimately could help to improve the ethics of clinical care.
The next three articles look at issues of fairness and equity in healthcare policy. In “Normal Functioning and Public Reason,” Michele Loi focuses on the task of identifying which human needs count as healthcare needs that make just claims on social resources for resolution or amelioration. He finds Norman Daniels’s argument that relies on an allegedly scientific distinction between normal function and pathology to be flawed. The domain of health needs seems larger than that defined by Daniels, and Loi moves ahead to argue for an account that allows for normative views.
Kristin Voigt’s article, “Appeals to Individual Responsibility for Health: Reconsidering the Luck Egalitarian Perspective,” distinguishes between three common appeals to individual responsibility that appear in discussions and debates about the fair distribution of healthcare resources: those that use individual responsibility as a rationing criterion, those that involve the promotion of incentives to encourage healthier behaviors, and those that tie individual responsibility to a notion of fair reciprocity. Voigt goes on to consider these concepts in light of recent developments in the literature surrounding a more nuanced interpretation of luck egalitarianism.
In “Blood in a Time of Scarcity,” Alister Browne examines Canada’s recent contingency plan for potential blood shortages, in which the availability of blood is divided into three phases: green, amber, and red. In the green phase, business is carried on as usual; in the amber, elective procedures are cancelled; and in the red, life-and-death decisions between patients have to be made. The plan recommends that in the green phase guidelines should be written for what to do in the red phase but does not say how those guidelines should read. Browne fills the gap here by developing a theory of allocative justice that derives from John Rawls’s A Theory of Justice and then uses that theory to propose guidelines about how to allocate blood in the red phase.
In light of the increased number of patients crossing borders and seeking care far from home, Leigh Turner’s article, “Transnational Medical Travel: Ethical Dimensions of Global Healthcare,” examines some of the numerous ethical, legal, and public health issues—and possible harmful consequences—raised by medical travel and the rapid expansion of the globalization of healthcare. He calls for bioethicists and other scholars to help prospective medical travelers, healthcare professionals, and policymakers address these concerns and questions, which are becoming ever more pressing as medical travel increases.
The next two articles address changes in policies that need to be expanded or reexamined. In her article, “The (Ab)use of Those with No Other Hope? Ethical and Legal Safeguards for Recipients of Experimental Procedures,” Sara Fovargue does not challenge the position that it can be justified for patients to participate in “research that may be beyond the bounds of current clinical research practice.” However, the author draws attention to some of the issues that are raised by involving in such experimental procedures those who are desperately ill and have no alternatives. Because of their particular vulnerability, she questions whether the existing regulatory structures offer appropriate protection.
Walter Glannon, in “The Moral Insignificance of Death in Organ Donation,” offers reasons for questioning and rethinking established views on the relation between death and harm in organ donation. He offers conditions that do not require donors to be dead, permanently unconscious, or imminently dying before organ procurement can proceed.
In another journal entry, Kazin muses that “values are our only home in the universe.” But values—even our own—are not self-evident, as the complexities of these articles illustrate. Inevitably, the articles in this collection raise questions that they do not answer. We welcome your comments and responses.
