Health Care Analysis

Are We Justified in Introducing Carbon Monoxide Testing to Encourage Smoking Cessation in Pregnant Women? Abstract Smoking is frequently presented as being particularly problematic when the smoker is a pregnant woman because of the potential harm to the future child. This premise is used to justify targeting pregnant women with a unique approach to smoking cessation including policies such as the routine testing of all pregnant women for carbon monoxide at every antenatal appointment. This paper examines the evidence that such policies are justified by the aim of harm prevention and argues that targeting pregnant women in this way is likely to do more harm than good. Routine carbon monoxide testing is particularly problematic as it sends a message to pregnant women that they cannot be trusted either to truthfully answer questions as to whether or not they smoke, or to make decisions in the best interests of themselves and their future children in the way that non-pregnant individuals are. Further, if the aim is to reduce rates of prenatal harm, the evidence suggests that adopting a supportive and empowering approach to prenatal care is the most effective way to achieve this, something that the current policies aimed at pregnant women are in conflict with.

Between the Reasonable and the Particular: Deflating Autonomy in the Legal Regulation of Informed Consent to Medical Treatment Abstract The law of informed consent to medical treatment has recently been extensively overhauled in England. The 2015 Montgomery judgment has done away with the long-held position that the information to be disclosed by doctors when obtaining valid consent from patients should be determined on the basis of what a reasonable body of medical opinion agree ought to be disclosed in the circumstances. The UK Supreme Court concluded that the information that is material to a patient's decision should instead be judged by reference to a new two-limbed test founded on the notions of the 'reasonable person' and the 'particular patient'. The rationale outlined in Montgomery for this new test of materiality, and academic comment on the ruling's significance, has focused on the central ethical importance that the law now (rightfully) accords to respect for patient autonomy in the process of obtaining consent from patients. In this paper, we dispute the claim that the new test of materiality articulated in Montgomery equates with respect for autonomy being given primacy in re-shaping the development of the law in this area. We also defend this position, arguing that our revised interpretation of Montgomery's significance does not equate with a failure by the courts to give due legal consideration to what is owed to patients as autonomous decision-makers in the consent process. Instead, Montgomery correctly implies that doctors are ethically (and legally) obliged to attend to a number of relevant ethical considerations in framing decisions about consent to treatment, which include subtle interpretations of the values of autonomy and well-being. Doctors should give appropriate consideration to how these values are fleshed out and balanced in context in order to specify precisely what information ought to be disclosed to a patient as a requirement of obtaining consent, and as a core component of shared decision-making within medical encounters more generally.

Principles of Need and the Aggregation Thesis Abstract Principles of need are constantly referred to in health care priority setting. The common denominator for any principle of need is that it will ascribe some kind of special normative weight to people being worse off. However, this common ground does not answer the question how a plausible principle of need should relate to the aggregation of benefits across individuals. Principles of need are sometimes stated as being incompatible with aggregation and sometimes characterized as accepting aggregation in much the same way as utilitarians do. In this paper we argue that if one wants to take principles of need seriously both of these positions have unreasonable implications. We then characterize and defend a principle of need consisting of sufficientarian elements as well as prioritarian which avoids these unreasonable implications.

Evidence, Emotion and Eminence: A Qualitative and Evaluative Analysis of Doctors' Skills in Macroallocation Abstract In this analysis of the ethical dimensions of doctors' participation in macroallocation we set out to understand the skills they use, how they are acquired, and how they influence performance of the role. Using the principles of grounded moral analysis, we conducted a semi-structured interview study with Australian doctors engaged in macroallocation. We found that they performed expertise as argument, bringing together phronetic and rhetorical skills founded on communication, strategic thinking, finance, and health data. They had made significant, purposeful efforts to gain skills for the role. Our findings challenge common assumptions about doctors' preferences in argumentation, and reveal an unexpected commitment to practical reason. Using the ethics of Paul Ricoeur in our analysis enabled us to identify the moral meaning of doctors' skills and learning. We concluded that Ricoeur's ethics offers an empirically grounded matrix for ethical analysis of the doctor's role in macroallocation that may help to establish norms for procedure.

Irresponsibly Infertile? Obesity, Efficiency, and Exclusion from Treatment Abstract Many countries tightly ration access to publicly funded fertility treatments such as in vitro fertilisation (IVF). One basis for excluding people from access to IVF is their body mass index. In this paper, I consider a number of potential justifications for such a policy, based on claims about effectiveness and cost-efficiency, and reject these as unsupported by available evidence. I consider an alternative justification: that those whose subfertility results from avoidable behaviours for which they are responsible are less deserving of treatment. I ultimately stop short of endorsing or rejecting such a justification, though highlight some reasons for thinking it is unlikely to be practicable.

Risk, Overdiagnosis and Ethical Justifications Abstract Many healthcare practices expose people to risks of harmful outcomes. However, the major theories of moral philosophy struggle to assess whether, when and why it is ethically justifiable to expose individuals to risks, as opposed to actually harming them. Sven Ove Hansson has proposed an approach to the ethical assessment of risk imposition that encourages attention to factors including questions of justice in the distribution of advantage and risk, people's acceptance or otherwise of risks, and the scope individuals have to influence the practices that generate risk. This paper investigates the ethical justifiability of preventive healthcare practices that expose people to risks including overdiagnosis. We applied Hansson's framework to three such practices: an 'ideal' breast screening service, a commercial personal genome testing service, and a guideline that lowers the diagnostic threshold for hypertension. The framework was challenging to apply, not least because healthcare has unclear boundaries and involves highly complex practices. Nonetheless, the framework encouraged attention to issues that would be widely recognised as morally pertinent. Our assessment supports the view that at least some preventive healthcare practices that impose risks including that of overdiagnosis are not ethically justifiable. Further work is however needed to develop and/or test refined assessment criteria and guidance for applying them.

Why the Elective Caesarean Lottery is Ethically Impermissible Abstract In the United Kingdom the law and medical guidance is supportive of women making choices in childbirth. NICE guidelines are explicit that a competent woman's informed request for MRCS (elective caesarean in the absence of any clinical indications) should be respected. However, in reality pregnant women are routinely denied MRCS. In this paper I consider whether there is sufficient justification for restricting MRCS. The physical and emotive significance of childbirth as an event in a woman's life cannot be understated. It is, therefore, concerning that women are having their wishes ignored, and we must ascertain whether the denial of agency is justifiable. To answer this question I first demonstrate that access to MRCS is a lottery in the UK. Second, I argue that there is nothing unique about pregnancy that displaces the ethical norm of respecting patents' sufficiently autonomous choices. Thus, the starting presumption is that all informed choices regarding MRCS should be respected. To ascertain whether any restriction of MRCS is justifiable the burden of proof must be placed on those who argue that MRCS is ethically impermissible. I argue that the most common justifications in the literature against MRCS are insufficient to displace the presumption in favour of autonomous choice in childbirth. I conclude that MRCS should be available to pregnant women, and we must strive to reduce the lottery in access to choice.

Perils of Professionalization: Chronicling a Crisis and Renewing the Potential of Healthcare Management Abstract This paper critically examines efforts to "professionalize" the field of healthcare management and its corresponding costs. Drawing upon the scholarly critiques of professionalization in medicine and the broader field of management, this paper seeks to explore the symbolic role professionalization might play in the psyche of its constituents, and specifically its function as a defense against uncertainty and anxiety. This psychodynamic heuristic is then deployed to put forth the hypothesis that an ongoing crisis of professional identity continues to both propel and impede professionalization efforts in healthcare management, giving rise to a litany of standardization pressures that ultimately limit the field's potential. To mitigate these pressures, the call is made for rekindling healthcare management's moral, political, and existential aspects. Specifically, this entails engaging with the deeper themes that flow through the field: the experience of illness and what it means to suffer, the experience of life and what it means to have hope, and the experience of death and dying. It also entails squarely confronting questions of power, poverty and disease, and the pursuit of justice.

'Effective' at What? On Effective Intervention in Serious Mental Illness Abstract The term "effective," on its own, is honorific but vague. Interventions against serious mental illness may be "effective" at goals as diverse as reducing "apparent sadness" or providing housing. Underexamined use of "effective" and other success terms often obfuscates differences and incompatibilities in interventions, degrees of effectiveness, key omissions in effectiveness standards, and values involved in determining what counts as "effective." Yet vague use of such success terms is common in the research, clinical, and policy realms, with consequences that negatively affect the care offered to individuals experiencing serious mental illness. A pragmatist-oriented solution to these problems suggests that when people use success terms, they need to explain and defend the goals and supporting values embedded in the terms, asking and answering the questions, "Effective at what? For whom? How effective? And why that goal?" Practical and epistemic standards for effectiveness will likely remain plural for good reasons, but each standard should be well explained and well justified.

The Fundamental Importance of the Normative Analysis of Health