Fair equality of opportunity critically reexamined: the family and the sustainability of health care systems.

A complex interaction of ideological, financial, social, and moral factors makes the financial sustainability of health care systems a challenge across the world. One difficulty is that some of the moral commitments of some health care systems collide with reality. In particular, commitments to equality in access to health care and to fair equality of opportunity undergird an unachievable promise, namely, to provide all with the best of basic health care. In addition, commitments to fair equality of opportunity are in tension with the existence of families, because families are aimed at advantaging their own members in preference to others. Because the social-democratic state is committed to fair equality of opportunity, it offers a web of publicly funded entitlements that make it easier for persons to exit the family and to have children outside of marriage. In the United States, in 2008, 41% of children were born outside of wedlock, whereas, in 1940, the percentage was only 3.8%, and in 1960, 5%, with the further consequence that the social and financial capital generated through families, which aids in supporting health care in families, is diminished. In order to explore the challenge of creating a sustainable health care system that also supports the traditional family, the claims made for fair equality of opportunity in health care are critically reconsidered. This is done by engaging the expository device of John Rawls's original position, but with a thin theory of the good that is substantively different from that of Rawls, one that supports a health care system built around significant copayments, financial counseling, and compulsory savings, with a special focus on enhancing the financial and social capital of the family. This radical recasting of Rawls, which draws inspiration from Singapore, is undertaken as a heuristic to aid in articulating an approach to health care allocation that can lead past the difficulties of social-democratic policy.

Bioethics critically reconsidered: living after foundations.

Given intractable moral pluralism, what ought one to make of the bioethics that arose in the early 1970s, grounded as it was in the false assumption that there is a common secular morality that secular bioethics ought to apply? It is as if bioethics developed without recognition of the crisis at the heart of secular morality itself. Secular moral rationality cannot of itself provide the foundations to identify a particular morality and its bioethics as canonical. One is not just confronted with intractable moral and bioethical pluralism, but with the absence of a secular ground that can show why one should act morally rather than self-interestedly. The result is not merely the deflation of much of traditional Western morality to life-style and death-style choices, but the threat of deflating to political slogans the now-dominant secular morality, including its affirmation of human autonomy, equality, social justice, and human dignity. All of this invites one critically to reconsider the meaning and force of secular bioethics.

Core competencies for health care ethics consultants: in search of professional status in a post-modern world.

The American Society for Bioethics and the Humanities (ASBH) issued its Core Competencies for Health Care Ethics Consultation just as it is becoming ever clearer that secular ethics is intractably plural and without foundations in any reality that is not a social-historical construction (ASBH Core Competencies for Health Care Ethics Consultation, 2nd edn. American Society for Bioethics and Humanities, Glenview, IL, 2011). Core Competencies fails to recognize that the ethics of health care ethics consultants is not ethics in the usual sense of a morally canonical ethics. Its ethics is the ethics established at law and in enforceable health care public policy in a particular jurisdiction. Its normativity is a legal normativity, so that the wrongness of violating this ethics is simply the legal penalties involved and the likelihood of their being imposed. That the ethics of ethics consultation is that ethics legally established accounts for the circumstance that the major role of hospital ethics consultants is as quasi-lawyers giving legal advice, aiding in risk management, and engaging in mediation. It also indicates why this collage of roles has succeeded so well. This article shows how moral philosophy as it was reborn in the 13th century West led to the ethics of modernity and then finally to the ethics of hospital ethics consultation. It provides a brief history of the emergence of an ethics that is after morality. Against this background, the significance of Core Competencies must be critically reconsidered.

Confronting moral pluralism in posttraditional Western societies: bioethics critically reassessed.

In the face of the moral pluralism that results from the death of God and the abandonment of a God's eye perspective in secular philosophy, bioethics arose in a context that renders it essentially incapable of giving answers to substantive moral questions, such as concerning the permissibility of abortion, human embryonic stem cell research, euthanasia, etc. Indeed, it is only when bioethics understands its own limitations and those of secular moral philosophy in general can it better appreciate those tasks that it can actually usefully perform in both the clinical and academic setting. It is the task of this paper to understand and reevaluate bioethics by understanding these limits. Academic bioethicists can analyze ideas, concepts, and claims necessary to understanding the moral questions raised in health care, assessing the arguments related to these issues, and provide an understanding of the different moral perspectives on bioethical issues. In the clinical setting, bioethicists can provide legal advice, serve as experts on IRBs, mediating disputes, facilitating decision-making and risk management, and clarifying normative issues. However, understanding this is only possible when one understands the history, genesis, and foundations of bioethics and its inability to provide a resolution to postmodern moral pluralism.

Beyond the best interests of children: four views of the family and of foundational disagreements regarding pediatric decision making.

This paper presents four different understandings of the family and their concomitant views of the authority of the family in pediatric medical decision making. These different views are grounded in robustly developed, and conflicting, worldviews supported by disparate basic premises about the nature of morality. The traditional worldviews are often found within religious communities that embrace foundational metaphysical premises at odds with the commitments of the liberal account of the family dominant in the secular culture of the West. These disputes are substantial and ultimately irresolvable by sound rational argument because of the failure to share common foundational premises and rules of evidence. It is in light of these fundamental disagreements that there is a need to evaluate critically the claims and agenda advanced by the Convention on the Rights of the Child.

Long-term care: the family, post-modernity, and conflicting moral life-worlds.

Long-term care is controversial because it involves foundational disputes. Some are moral-economic, bearing on whether the individual, the family, or the state is primarily responsible for long-term care, as well as on how one can establish a morally and financially sustainable long-term-care policy, given the moral hazard of people over-using entitlements once established, the political hazard of media democracies promising unfundable entitlements, the demographic hazard of relatively fewer workers to support those in need of long-term care, the moral hazard to responsibility of shifting accountability to third parties, and the bureaucratic hazard of moving from individual and family choice to bureaucratic oversight. These disputes are compounded by controversies regarding the nature of the family (Is it to be regarded primarily as a socio-biological category, a fundamental ontological category of social reality, or a construct resulting from the consent of the participants?), as well as its legal and moral autonomy and authority over its members. As the disputes show, there is no common understanding of respect and human dignity that will easily lead out of these disputes. The reflections on long-term care in this issue underscore the plurality of moralities defining bioethics.

The injustice of enforced equal access to transplant operations: rethinking reckless claims of fairness.

The globalizing or totalizing imposition of a particular understanding of justice, fairness, or equality, as seen, for example, in Canada's single health care system, which forbids the sale of private insurance and the purchase of better basic health care, cannot be justified in general secular terms because of the following limitations: (1) the plurality of understandings of justice, fairness, and equality, and (2) the inability to establish one understanding as canonical. The secular state lacks plausible moral authority for the coercive imposition of one such account on peaceable, consenting adults. This state of affairs, with regard to the weakness of human moral epistemological powers, means that the secular state fails to have the moral authority to forbid coercively the sale and purchase of organs. It further lacks the secular, moral authority to impose equal access to organ transplantations. Assertions of such authority amount to reckless claims of fairness, and for this reason, health care policy must be set within the constraints of limited, constitutional regimes.

Why ecumenism fails: taking theological differences seriously.

Contemporary Christians are separated by foundationally disparate understandings of Christianity itself. Christians do not share one theology, much less a common understanding of the significance of sin, suffering, disease, and death. These foundational disagreements not only stand as impediments to an intellectually defensible ecumenism, but they also form the underpinnings of major disputes in the culture wars, particularly as these are expressed in healthcare. There is not one Christian bioethics of sin, suffering, sickness, and death. In this article, the character of the moral-theological visions separating the various Christianities and thus their bioethics is examined. Particular emphasis is placed on the differences that set contemporary Western theology at odds with the theology of the Christianity of the first millennium. As is shown, the ground for this gulf lies in the divide between traditional and post-traditional views of the appropriate role of philosophy in theology, a difference rooted in disparate understandings of the meaning of church and of the meaning of the logos, the Son of God.

Sin and bioethics: why a liturgical anthropology is foundational.

The project of articulating a coherent, canonical, content-full, secular morality-cum-bioethics fails, because it does not acknowledge sin, which is to say, it does not acknowledge the centrality of holiness, which is essential to a non-distorted understanding of human existence and of morality. Secular morality cannot establish a particular moral content, the harmony of the good and the right, or the necessary precedence of morality over prudence, because such is possible only in terms of an ultimate point of reference: God. The necessity of a rightly ordered appreciation of God places centrally the focus on holiness and the avoidance of sin. Because the cardinal relationship of creatures to their Creator is worship, and because the cardinal corporate act of human worship is the Liturgy, morality in general and bioethics in particular can be understood in terms of the conditions necessary, so as worthily to enter into Eucharistic liturgical participation. Morality can be summed up in terms of the requirements of ritual purity. A liturgical anthropology is foundational to an account of the content-full morality and bioethics that should bind humans, since humans are first and foremost creatures obliged to join in rightly ordered worship of their Creator. When humans worship correctly, when they avoid sin and pursue holiness, they participate in restoring created reality.

Critical care: why there is no global bioethics.

PURPOSE OF REVIEW: The possibility of content-full, universal, bioethical norms is assessed. The literature brings into question a global bioethics. A salient moral and bioethical pluralism undermines the plausibility of imposing of uniform bioethical norms on critical care. Addressing the tension between the aspiration to a global bioethics and the presence of moral pluralism is timely, given the United Nations Educational, Scientific and Cultural Organization's development of universal, bioethical norms. The practice of critical care in the 21st century will be influenced by the tension between bioethical pluralism and counter-assertions on behalf of a global bioethics. RECENT FINDINGS: A growing literature reflects a bioethical pluralism with significant implications for critical care. Much of the literature supporting pluralism is rooted in a reaction in the Pacific Rim against North American and Western European moral and philosophical commitments. These voices of moral dissent join an already salient moral diversity in the West regarding issues ranging from abortion to end-of-life decision-making, physician-assisted suicide, and euthanasia, as well as conflicting understandings of the bioethics of appropriate approaches to the allocation of scarce medical resources. This literature acknowledging bioethical diversity contrasts with announcements of universal bioethical norms. SUMMARY: Clinicians need to appreciate the sources of moral controversy that divide them from their patients and from their colleagues and to recognize that moral and economic differences may lead to different standards of care. Taking bioethical diversity seriously supports focusing on procedural moral approaches that allow peaceable collaboration in the face of substantive moral disagreement.

The bioethics of care: widows, monastics, and a Christian presence in health care.

At the beginning of the twenty-first century, with vocations to the Christian religious orders of the West in marked decline, an authentic Christian presence in health care is threatened. There are no longer large numbers of women willing to offer their life labors bound in vows of poverty, chastity, and obedience, so as to provide a real preferential option for the poor through supporting an authentic Christian mission in health care. At the same time, the frequent earlier death of men leaves a large number of widows, some in need of care and some able to provide care. Drawing on the role of widows sketched in 1 Timothy 2, one can envision Christian widows entering a life of prayer and service in health care settings. As female monastics, such widows could reintroduce a salient Christian presence in health care. How one ties this response to the message of 1 Timothy 2 will depend on one's understanding of the status of Scripture, the significance of tradition, the nature of theological epistemology, the meaning of theology, the nature of the Church, and the ontology of gender. The position taken on these issues will define the character of a Christian bioethics of care.

The precautionary principle: a dialectical reconsideration.

This essay examines an overlooked element of the precautionary principle: a prudent assessment of the long-range or remote catastrophes possibly associated with technological development must include the catastrophes that may take place because of the absence of such technologies. In short, this brief essay attempts to turn the precautionary principle on its head by arguing that, (1) if the long-term survival of any life form is precarious, and if the survival of the current human population is particularly precarious, especially given contemporary urban population densities, and (2) if technological innovation and progress are necessary in order rapidly to adapt humans to meet environmental threats that would otherwise be catastrophic on a large scale (e.g., pandemics of highly lethal diseases), then (3) the development of biomedical technologies in many forms, but in particular including human germ-line genetic engineering, may be required by the precautionary principle, given the prospect of the obliteration of humans in the absence of such enhanced biotechnology. The precautionary principle thus properly understood requires an ethos that should generally support technological innovation, at least in particular areas of biotechnology.

Informed consent in Texas: theory and practice.

The legal basis of informed consent in Texas may on first examination suggest an unqualified affirmation of persons as the source of authority over themselves. This view of individuals in the practice of informed consent tends to present persons outside of any social context in general and outside of their families in particular. The actual functioning of law and medical practice in Texas, however, is far more complex. This study begins with a brief overview of the roots of Texas law and public policy regarding informed consent. This surface account is then contrasted with examples drawn from the actual functioning of Texas law: Texas legislation regarding out-of-hospital do-not-resuscitate (DNR) orders. As a default approach to medical decision-making when patients lose decisional capacity and have failed to appoint a formal proxy or establish their wishes, this law establishes a defeasible presumption in favor of what the law characterizes as "qualified relatives" who can function as decision-makers for those terminal family members who lose decisional capacity. The study shows how, in the face of a general affirmation of the autonomy of individuals as if they were morally and socially isolated agents, space is nevertheless made for families to choose on behalf of their own members. The result is a multi-tier public morality, one affirming individuals as morally authoritative and the other recognizing the decisional standing of families.

Moral knowledge: some reflections on moral controversies, incompatible moral epistemologies, and the culture wars.

An authentic Christian bioethical account of abortion must take into consideration the conflicting epistemologies that separate Christian moral theology from secular moral philosophy. Moral epistemologies directed to the issue of abortion that fail to appreciate the orientation of morality to God will also fail adequately to appreciate the moral issues at stake. Christian accounts of the bioethics of abortion that reduce moral-theological considerations to moral-philosophical considerations will not only fail to appreciate fully the offense of abortion, but morally mislead. This article locates the bioethics of abortion within the theology of the Church of the first millennium, emphasizing that abortion was prohibited, whether or not one considered the embryo or fetus to be ensouled.

The new genetic technologies: why a theological perspective is necessary.

Secular bioethics poses questions that can be recognized as important, though it lacks the resources to answer them. Secular bioethics may retain the sense that there should be moral limits to the use of germline genetic engineering, but it lacks the basis to justify limits in principle. The contemporary practice of bioethics arose in the United States to fill a moral vacuum created by (1) the marginalization of medical ethics through the deprofessionalization of medicine, (2) the secularization of American society, and (3) an increased reliance on individual decision-making. The result is an ethics at the core of secular bioethics severed from a sense of ultimate purpose or direction for humans or the cosmos. This ethics and its bioethics are marked by (1) moral fragmentation and pluralism and (2) a loss of ultimate orientation. This bioethics can at best require (1) the prudent maximization of benefits over harms, (2) the condemnation of malevolent acts, and (3) the use of persons only with their consent. However, there fails to be a basis for a common view of benefit or of harm. Within this impoverished moral context, human biological nature can only appear to be a contingent outcome of spontaneous mutations, selective pressure, the constraints of physical laws, and random catastrophes. Such a bioethics, deprived of ultimate orientation, can provide no ground in principle for forbidding cloning, germline genetic engineering, or the fundamental recasting of human nature. Absent a theological point of orientation, medicine and the genetic technology are left with more power than ever but no clear moral sense of how to use that power.