In the Hastings Center Report's July‐August 2022 issue, articles by Jessica Amalraj and Kavita Shah Arora and by Inmaculada de Melo‐Martín take up very different concerns under the broad topic of reproductive ethics and public policy. Amalraj and Arora call for public deliberation and consensus building to revise a Medicaid sterilization policy, and de Melo‐Martín argues that social resources should not be used to support reproductive embryo editing but should instead be put toward pre‐ and postnatal (...) interventions that, compared to embryonic genome editing, can help far more people have children who are healthy and genetically related to them. The third article, by Bryan Sisk and James M. DuBois, offers a framework to guide clinicians in their everyday communication with patients and their family members. Elsewhere in the issue are arguments about the responsibilities health care organizations have to address large societal problems affecting well‐being. (shrink)

Due to a history of coerced sterilization, a federal Medicaid sterilization policy mandates that a specific consent form be signed by a patient at least thirty days prior to when the patient undergoes sterilization. However, in contemporary obstetrical practice, the Medicaid sterilization policy serves as a policy‐level barrier to autonomously desired care. We review the clinical and ethical implications of the current Medicaid sterilization policy. After discussing the utility (...) and impact of waiting periods for other surgical procedures, we explore the psychology of time required for decision‐making and consider scientific understanding of regret. We argue that the current Medicaid sterilization waiting period is clinically and ethically unjustifiable and that the policy ought to be revised in light of the goals, preferences, and concerns of the people most affected by it. While the need for continued protection against coercion remains, the current mandated waiting period does little to enforce the high‐quality shared decision‐making that is desired for sterilization counseling. (shrink)

[P]layers line up in a long line and hold hands. The player at the front of the line is the ‘head’ and the player at the end of the line is the ‘tail’.… The game begins when the head begins to run wildly in any direction, making sharp turns and quick double-backs.… The force created by the twists and turns will often send the tail of the whip flying.… It may be best for the tail to hold on with both (...) hands to keep from flying off the end. Sometimes, however, the tail will go flying no matter how hard they hold on... Be prepared to get dirty if you play this game!--"Crack the Whip: Party Game CentralIf the evolution of American health policy is compared to the children’s game of Crack the Whip, then there is no question that the Medicaid program is the tail of the line. When those at the head of the line start to move. Medicaid receives whatever shocks and unintended consequences result, and when the line “begins to run wildly in any direction,” it receives them faster and harder than the players at the center.Shocks also come from other sources. When the economy slumps, an epidemic arises, or a path in another part of the system becomes a cul-de-sac, new twists and turns occur, with Medicaid absorbing much of the change. (shrink)

We cannot easily condemn in principle a policy where people are non-voluntarily sterilized with their informed consent (where they accept sterilization, if they do, in order to avoid punishment). There are conceivable circumstances where such a policy would be morally acceptable. One such conceivable circumstance is the one (incorrectly, as it were) believed by most decent advocates of eugenics in the late nineteenth and early twentieth century to exist: to wit, a situation where the human race as (...) such is facing a threat. Perhaps today's Chinese experience with a threat of overpopulation is a more realistic example? Finally, there is some room for a kind of non-voluntary (and coercive) sterilization without informed consent. I think of people who are severely mentally retarded, and who cannot understand how sexual intercourse relates to conception. If some of these persons are fertile and sexually active, it may very well be the morally right thing to do to sterilize these persons, in their own best interest, but without their consent - if necessary even through coercive means. (shrink)

Federal and state budgetary constraints continually challenge Medicaid. The effects of benefit cuts are common: long waiting lists for community‐based services, skeletonized drug formularies with unstable access to long‐term prescriptions, no psychiatric therapy for people immobilized by depression, and no more than fourteen days of acute hospitalization. Reimbursements may be so low that providers cannot hire qualified staff and must reduce services, close facilities, or refuse to take Medicaid altogether. Misguided efficiency policies may afflict some groups of patients (...) as well. Decisions to narrow access rights to publicly funded health care promote the perception that more broadly inclusive programs would be unwisely and unfairly generous. They also risk characterizing disability rights as “special,” confined to a narrow class of people who charitably ought not to be expected to provide for themselves. In contrast, on a philosophical view we have been exploring—one that addresses problems of justice under circumstances of injustice by pursuing rather than reducing inclusion—efforts like these are unjust. (shrink)

American policymakers delegate the administration of many welfare programs to states, where officials implement them in increasingly diverse ways. Welfare state scholarship has little to say about this subnational policy divergence, and it portrays the complexity of delegated governance as a barrier to nonelite legislative influence. Drawing on an ethnographic study of one state’s Medicaid program, this article shows that delegated governance offers ample opportunity for nonelite influence and policy divergence, but through regulatory governance rather than legislative (...) advocacy. Medicaid is opaque to politicians, whose inability to monitor program details creates conditions of bureaucratic autonomy and even activism: health-care agency personnel sequence regulatory tweaks to protect and expand entitlements. But budget cuts, outsourcing, and fraught provider relations also deprive bureaucrats of street-level know-how, and bureaucrats depend on beneficiaries’ advocates who selectively illuminate a path to reform. A full rendering of subnational divergence in American federalism requires attention to underexamined factors such as bureaucratic activism, agency advocacy, and regulatory governance. (shrink)

This article assesses interactions between American and German eugenicists in the interwar period. It shows the shifting importance and leading roles of German and American eugenicists: while interactions and exchanges between German and American eugenicists in the interwar period were important and significant, it remains difficult to establish direct American influence on Nazi legislation. German experts of race hygiene who advised the Nazi government in drafting the sterilization law were well informed about the experiences with similar laws in American (...) states, most importantly in California and Virginia, but there is little evidence to suggest they depended on American knowledge and expertise to draft their own sterilization law. Rather, they adapted a body of thought that was transnational by nature: suggesting that the Nazis’ racial policies can be traced back to American origins over-simplifies the historical record. Still, the ‘American connection’ of the German racial hygiene movement is a significant aspect of the general history of eugenics into which it needs to be integrated. The similarities in eugenic thinking and practice in the USA and Germany force us to re-evaluate the peculiarity of Nazi racial policies. (shrink)

In the face of escalating Medicaid costs and anticipated reductions in federal Medicaid spending, states are increasingly converting from fee-for-service to managed health care systems. The interrelated issues of enrollment and auto-assignment are fundamental to the overall success or failure of Medicaid managed care programs. The purpose of this article is to suggest how policy makers, consumer advocates, and providers should address these issues. My major premise is that implementation of managed care will proceed more smoothly (...) if states adopt enrollment strategies that promote voluntary selection of health plans by Medicaid consumers, minimize the likelihood of auto-assignment, and mitigate the negative consequences of mandatory assignment of consumers to managed care organizations.States seeking to implement Medicaid managed care must apply for a waiver from the secretary of the Department of Health and Human Services. Two different types of waivers are available to implement Medicaid managed care. (shrink)

Abstract:This essay criticizes recent trends in disability policy as restrictive of individual liberty and informed by too narrow a definition of what constitutes human flourishing. I defend the value of intentional community settings as one legitimate residential option for people with intellectual and developmental disabilities. Recent federal regulations (HCBS Final Rule) define intentional communities or disability-specific housing as presumptively institutional in nature, misunderstanding the positive, noninstitutional features of intentional, integrated communities created by and for people with developmental disabilities. In (...) addition, current disability policy, despite its stated concern for the autonomy of people with intellectual and developmental disabilities, limits individual liberty by strictly defining the types of settings eligible for Medicaid waiver funding, expressly excluding agricultural communities, disability-specific residential settings, and intentional communities. A robust commitment to the autonomy of people receiving Medicaid waiver services would allow them to choose to direct their program dollars, recognizing that some individuals may choose a life in intentional community or with others facing similar challenges to themselves over an illusory “integration” into a wider society that remains too often unwelcoming and difficult to navigate. (shrink)

This paper argues against incorporating assessments of individual responsibility into healthcare policies by expanding an existing argument and offering a rebuttal to an argument in favour of such policies. First, it is argued that what primarily underlies discussions surrounding personal responsibility and healthcare is not causal responsibility, moral responsibility or culpability, as one might expect, but biases towards particular highly stigmatised behaviours. A challenge is posed for proponents of taking personal responsibility into account within health policy to either expand (...) the debate to also include socially accepted behaviours or to provide an alternative explanation of the narrowly focused discussion. Second, a critical response is offered to arguments that claim that policies based on personal responsibility would lead to several positive outcomes including healthy behaviour change, better health outcomes and decreases in healthcare spending. It is argued that using individual responsibility as a basis for resource allocation in healthcare is unlikely to motivate positive behaviour changes, and is likely to increase inequality which may lead to worse health outcomes overall. Finally, the case of West Virginia's Medicaid reform is examined, which raises a worry that policies focused on personal responsibility have the potential to lead to increases in medical spending overall. (shrink)

The welfare reform law of 1996 completely overhauled the nation's system of assistance to low-income families. The reauthorization of that law, now several months overdue because of congressional delays, presents an opportunity for religious social ethicists to evaluate the adequacy of our nation's anti-poverty efforts. This paper surveys policy developments from 1996 to 2003 and analyzes five key issues in the reauthorization debate: the size and structure of welfare block grants; work requirements; welfare time limits, sanctions, and exemptions; marriage (...) promotion and the family cap; and ancillary programs providing work supports such as food stamps, Medicaid, and child care subsidies. A variety of ethical critiques of policy proposals is offered, some of them from the perspective of Catholic social teaching. The trail of missed opportunities in welfare reform will probably continue, as American social policy fails to act upon an accurate portrayal of the challenges facing poor families today. (shrink)

Policymakers use financial incentives to achieve a wide variety of public objectives, from pollution reduction to the employment of welfare recipients. Combining insights from economic theory with lessons learned from actual implementation, this article analyzes the implications of two such policies: first, subsidizing contraception, and second, offering financial incentives to individuals for sterilization or for using a long-term, semipermanent method of contraception such as the Intra-Uterine Device, Depo-Provera or Norplant. These subsidy and incentive policies achieve their goals through a (...) myriad of individuals who make their reproductive choices in response to particular costs and benefits. Such programs are ethically and politically controversial. In this paper, I address the question of whether they can be justified either economically or ethically.The first section of this article presents an economic theory to assess whether a subsidy, tax, or incentive is economically efficient, both generally and in the context of contraception. (shrink)

In public health and the social sciences, there is growing recognition of the role that social context plays in determining health. Frequently, social relations of inequality are among the most important features of social context identified in this work, and emphasis is placed on identifying and addressing these inequalities in order to improve health. Within the field of HIV/AIDS prevention as well, researchers have begun to look beyond individuals for an understanding of the structural causes of HIV-related risk. This research (...) demands that greater attention be paid to the social mechanisms and contextual factors that lead to HIV risk. Among these factors are law and social policy, which form a part of the context in which risk-taking occurs and which can promote both HIV transmission and prevention. On the one hand, laws limiting access to sterile injection equipment have contributed to HIV-related risk behavioxs among injection drug users. (shrink)

Delivering high quality genomics-informed care to patients requires accurate test results whose clinical implications are understood. While other actors, including state agencies, professional organizations, and clinicians, are involved, this article focuses on the extent to which the federal agencies that play the most prominent roles — the Centers for Medicare and Medicaid Services enforcing CLIA and the FDA — effectively ensure that these elements are met and concludes by suggesting possible ways to improve their oversight of genomic testing.

Despite some improvements in access to evidence-based medications for opioid use disorder, treatment rates remain low at under a quarter of those with need. High costs for brand name products in these medication markets have limited the volume of drugs purchased, particularly through public health insurance and grant programs. Brand firm anti-competitive practices around the leading buprenorphine product Suboxone — including product hops, citizen petitions and Risk Evaluation and Mitigation Strategy abuses — helped to maintain high prices by extending brand (...) exclusivity periods and hindering generic drug entry. Remedies to address costly anti-competitive activities include adoption of the proposed CREATES Act and modernization of the Hatch-Waxman Act by the Congress, and implementation of substantive modifications to the Food and Drug Administration citizen petition filing procedures. Given the persistence of these abuses, prescriptive changes are favorable to the procedural and clarifying steps thus far favored by the federal government. Extrapolating from the 37% price declines attributable to generic entry for buprenorphine tablets in 2011, our calculations suggest that implementing these remedies to facilitate generic competition with Suboxone film would have resulted in savings of approximately $703 million overall and $203 million to Medicaid in 2017. (shrink)

The market changes sweeping the U.S. health care industry have a distinctive impact on communities that rely on religiously affiliated health care providers. When a sectarian sponsor subsumes multiple providers, its assertion of religious beliefs can preclude the provision of certain health care services to the entire community. In addition, the sectarian provider's refusal to offer certain services may violate state certificates of need, licensing, Medicaid managed care, or even professional liability law. This situation challenges both the provider and (...) the state: the provider seeks adherence to religious law, and the state seeks compliance with its law and citizens access to health care.I propose that the state attempt to ameliorate tensions between civil and religious laws through negotiated accomodation. This concept encourages the sectarian institution to reassess its mission in the current market and to identify alternative avenues of health care delivery that will preserve patients' access to care without excessively diluting religious identity or beliefs. (shrink)

This is a volatile time for health insurance policy. Medicare and Medicaid are in turmoil, as is the private health insurance market. Public and private health insurance costs constitute eighty percent of healthcare spending in the United States. Public health professionals depend on the insurance system to behave in ways that are responsive to public health in prevention and crisis management.Seventy-five percent of the American population, excluding the elderly, has coverage through the private health insurance system. Ninety percent (...) of this group receives their insurance through employer-sponsored programs, and the remaining ten percent buy their own coverage. Approximately ten percent of the non-elderly population has insurance through a government program, and fifteen percent of the non-elderly population, almost forty-one million Americans, is uninsured. (shrink)

According to Vera Moser, the first professorship of healing pedagogy, Heilpädagogik at the University of Zürich in 1931, established pedagogy of the disabled as an academic discipline. Through the definition of the smallest common denominator for all disabilities, which Heinrich Hanselmann called “weakness of the soul,” a connecting element of “imbecility, deaf-mutism, blindness, neglect and idiocy” was established. Under Nazi rule, school pedagogy advanced to völkisch, nationalist special pedagogy, shifting from the category of “innate imbecility” to a broader concept of (...) disability. As an outcome of these programs and policies, 300,000 people with disabilities were killed as a part of the “T4 Aktion.” Within just a few decades after World War II, special pedagogy expanded its sphere of influence through professionalization and institutionalization in West and East Germany and across Europe. This paper explores how special pedagogy aligned itself with the Nazi regime’s discourse and policy on eugenics and race hygiene, leading to the murder and mass sterilization of “disabled” children and adults. It probes questions regarding the extent to which the professionalization of special pedagogy has drawn from the Nazi-era terminology of the deficient and foreign to legitimate the contemporary migrant bias in German and Austrian special pedagogical care. (shrink)

Women with opioid use disorder (OUD) face unique challenges meeting their reproductive goals. Because the rate of unintended pregnancy in this population is almost 80 percent, there has been a push to increase the use of contraceptives among reproductive-aged women with OUD.1 The patient-level ethical issues of such initiatives, however, are often overlooked. This review discusses the ethical issues in two realms: obtaining contraception when it is desired and avoiding contraceptive coercion when contraception is not desired. It is important that (...) access to reproductive education and care be improved to ensure autonomous decision making by women with OUD. It is also necessary to be mindful of the history of oppressive and coercive contraception and sterilization policies in the United States. These policies have left a legacy of mistrust and continue to be manifested in the form of more subtly oppressive policies in contemporary medical practice. Such policies point to the ongoing stigmatization of, and implicit biases held against, women with OUD. Based on these ethical issues, solutions are suggested at the clinical, systemic, and societal levels. (shrink)

This article explores the issue of forced sterilization of indigenous populations as a bioethical problem, from an interdisciplinary point of view based on historical sociology and in dialogue with medical anthropology, gender studies and human rights. Its methodology is based on the study of an empirical case, in connection with an ethnography carried out in a municipality of southern Mexico, in the state of Guerrero. It is complemented by a documentary research which allowed, among other things, the construction of (...) a theoretical case from the events that occurred in Peru, at the same time as the Mexican case, in the 1990s. The main finding of this historical research work is that forced sterilization, although largely due to a population control policy as well as certain family planning practices, is also related, in the particular case of indigenous peoples, to the counterinsurgency process against guerrillas, characteristic of those years in Latin America. (shrink)

Insurance coverage of abortion varies widely across the United States and is an extensively debated issue. Medicaid coverage of abortion is particularly relevant because the majority of abortion patients are poor or low‐income and are thus often covered by Medicaid. Since the Hyde Amendment was first passed in 1976, federal Medicaid funds have been banned from covering the costs of elective abortion. Although states are allowed to use their own funds to cover abortions for their Medicaid (...) recipients, only 17 states currently do so. Of these 17 states, only five cover abortion costs voluntarily; the others do so pursuant to court order. The medical literature includes few ethical analyses of the Hyde Amendment’s ban on Medicaid funding of elective abortions. To fill this gap, we perform an ethical analysis of federal policy to fund elective abortions using a consequentialist approach focused on consequences for pregnant women and their children. (shrink)

Projects of human improvement take both individual and intergenerational forms. The biosciences provide many technologies, including prenatal screening and the latest gene editing techniques, such as CRISPR, that have been viewed as providing the means to human improvement across generations. But who is fit to furnish the next generation? Historically, eugenics epitomizes the science-based attempt to improve human society through distinguishing kinds of people and then implementing social policies—from immigration restriction to sexual sterilization and euthanasia—that influence and even direct (...) what sorts of people populate our future. Despite recognition of the horrors of the eugenic extremes of the past and of the subhumanizing of those sufficiently below appearance or ability norms to be viewed as “defective” or “unfit”, many people continue to be drawn to strands of eugenic thinking. (shrink)

Each state’s Medicaid Fraud Control Unit prosecutes billing fraud cases against individual healthcare providers who fraudulently bill Medicaid for services provided. Once an individual is convicted of billing fraud, the Office of Inspector General for the Department of Health and Human Services may exclude the individual from billing any federal government healthcare program, including Medicaid. Excluded individuals are added to a public list of exclusions, which restricts their ability to practice professionally. Prompted by criminology research into the (...) impact of policing resources, we test whether these government enforcement initiatives against fraud serve as a deterrent to would-be fraudulent billers. We document that key enforcement proxies, the staffing level and budget of an MFCU, are positively associated with the yearly number of exclusions added at the state level. Our results are consistent with the exclusion list not being a deterrent but provide support for MFCUs’ fraud detection efforts. This paper provides industry-specific fraud insights for auditors and other individuals involved in public policy, specifically Medicaid, and introduces a novel dataset to the accounting fraud research literature. (shrink)

Recent estimates indicate that over 40,000 children die annually in the United States and a majority have life-limiting conditions. Children at end of life require extensive healthcare resources, including multiple hospital readmissions and emergency room visits. Yet, many children still suffer from symptoms at end of life—including fatigue, pain, dyspnea, and anxiety—with less than 10% of these children utilizing hospice care services. A critical barrier to pediatric hospice use was the original federal regulations associated with the hospice care that required (...) a diagnosis of 6 months to live and the discontinuation of all curative treatments. The Concurrent Care Provision of the United States’ Affordable Care Act eliminated the need to forgo curative therapies in order to enroll in hospice for children in Medicaid or Children’s Health Insurance Program. Concurrent care for children can help mitigate the tension families experience in choosing between essential forms of care, as well as contribute to improved end-of-life outcomes for the child and possibly bereavement outcomes for the family. Understanding concurrent care for children from a social justice perspective has important advocacy and research implications for hospice and palliative care clinicians providing care for children and their families. We apply Powers and Faden’s theory of social justice “as the moral foundation of public health and health policy” to the provision of concurrent care to children near end of life and families in the United States. The goals of applying this theory are to explore additional insights and perspectives into concurrent care policy may provide and to assess the usefulness of this theory when applied to end-of-life health policy. We argue that concurrent care policy is socially just since it has potential to promote well-being in vulnerable children and families and can limit the inequity children at end-of-life experience in access to high-quality hospice care. (shrink)

Ernst Rüdin was the founder of psychiatric genetics and was also a founder of the German racial hygiene movement. Throughout his long career he played a major role in promoting eugenic ideas and policies in Germany, including helping formulate the 1933 Nazi eugenic sterilization law and other governmental policies directed against the alleged carriers of genetic defects. In the 1940s Rüdin supported the killing of children and mental patients under a Nazi program euphemistically called “Euthanasia.” The authors document these (...) crimes and discuss their implications, and also present translations of two publications Rüdin co-authored in 1938 showing his strong support for Hitler and his policies. The authors also document what they see as revisionist historical accounts by leading psychiatric genetic authors. They outline three categories of contemporary psychiatric genetic accounts of Rüdin and his work: those who write about German psychiatric genetics in the Nazi period, but either fail to mention Rüdin at all, or cast him in a favorable light; those who acknowledge that Rüdin helped promote eugenic sterilization and/or may have worked with the Nazis, but generally paint a positive picture of Rüdin’s research and fail to mention his participation in the “euthanasia” killing program; and those who have written that Rüdin committed and supported unspeakable atrocities. The authors conclude by calling on the leaders of psychiatric genetics to produce a detailed and complete account of their field’s history, including all of the documented crimes committed by Rüdin and his associates. (shrink)

So-called “ugly laws” were mostly municipal statutes in the United States that outlawed the appearance in public of people who were, in the words of one of these laws, “diseased, maimed, mutilated, or in any way deformed, so as to be an unsightly or disgusting object” (Chicago City Code 1881). Although the moniker “ugly laws” was coined to refer collectively to such ordinances only in 1975 (Burgdorf and Burgdorf 1975), it has become the primary way to refer to such laws, (...) which targeted the overlapping categories of the poor, the homeless, vagrants, and those with visible disabilities. Enacted and actively enforced between the American Civil War (1867) and World War I (1918), such laws and their enforcement can tell us much about the very sorts of people who were also, a generation later, subject to explicitly eugenic laws, such as sterilization legislation. And like eugenic laws and policies, such laws continue to affect the lives of people with disabilities to this day (Schweik 2011). (shrink)

This paper seeks to understand the treatment effect of Prescription Drug Monitoring Programs on opioid prescription rates. Using county-level panel data on all opioid prescriptions in the U.S. between 2006 and 2015, we investigate whether state interventions like PDMPs have heterogeneous treatment effects at the sub-state level, based on regional and temporal variations in policy design, extent of urbanization, race, and income. Our models comprehensively control for a set of county and time fixed effects, countyspecific and time-varying demographic controls, (...) potentially endogenous time-series trends in prescription rates, and other state-level opioid interventions such as Naloxone Access and Good Samaritan laws, Medicaid expansion, and the provision of Methadone Assistance Treatment. We find that PDMPs are only effective in reducing prescription rates if they obligate doctors to check for patients' history prior to filling out a prescription, but the frequency at which a state requires its PDMP to be updated is irrelevant to its effectiveness. Moreover, the significant treatment effects of PDMPs are almost exclusively driven by urban and predominantly white counties, with the relatively more affluent regions showing greater responsiveness than their less affluent counterparts. (shrink)

We attempt to identify and evaluate the association between key characteristics of not-for-profit hospitals and market concentration, as measured by the Herfindahl–Hirschman Index, using data available from the American Hospital Association, the Centers for Medicare and Medicaid Services, and the Internal Revenue Service Form 990. Our goal is to provide decision support to policy makers on factors that contribute to market competitiveness, which has been linked to improvements in efficiency, costs, and access to health care. We find that (...) contributions are positively associated with market concentration. This could indicate that well-run NP hospitals are rewarded both financially as well as with increased market share. We also find that a higher percentage of Medicare patients is positively correlated with market concentration. This could be explained by the fact that Medicare reimbursement rates are generally lower than those paid by private insurers ; thus, hospitals might not necessarily choose to operate in areas with high Medicare populations. Further, median income is negatively associated with market concentration. One explanation for this effect could be the fact that a population with a higher median income is in a better position to pay for services, making them attractive to hospitals as a potential market. Finally, we find that the presence of managers with voting rights on the boards of directors has no significant impact. (shrink)

The United States, unlike all other industrialized nations, does not have a comprehensive public system for financing health care. Nevertheless, the magnitude of America's public health care financing effort is remarkable. Of the one trillion dollars the United States spent on health care in 1996, almost half, $483.1 billion, was spent by public programs. In 1995, Medicare—our social insurance program for persons over sixty-five and the long-term disabled—overed 37.5 million Americans; Medicaid—our program for indigent elderly and disabled persons and (...) indigent children and their families—covered 36.3 million. In 1996, Medicare and Medicaid spent $203.1 and $147.7 billion, respectively. The payment policies of these massive public health care programs have a profound effect on the provision of health care.Many of the recipients of Medicare and Medicaid suffer pain. In 1994, 376,200 Americans over age sixty-five died of cancer. Virtually all of these would have been Medicare recipients, and as many as 70 percent of them died in unrelieved pain. Nearly four million Americans over sixty-five endured the pain of inpatient surgery in 1995, again nearly all of whom were Medicare recipients. (shrink)

Florida is currently collecting data on the “costs of uncompensated care for aliens who are not lawfully present in the U.S.” (Statutes of Florida, 2023). The Florida data collection law, enacted in 2023, is part of aggressive anti-immigrant legislation. Hospitals accepting Medicaid must inquire about patients’ immigration status and submit de-identified reports. In August 2024, the Governor of Texas signed an Executive Order comparable to the Florida statute. Although presented as a data-collection measure, the legal requirements have far-reaching consequences. (...) The potential adverse impacts on immigrants’ health pose bioethical concerns. Immigration-related inquiries create barriers to healthcare access and advance care planning, exacerbating healthcare disparities and presenting ethical concerns. This article examines the effects on immigrants and the resulting ethical challenges, including respect for persons, beneficence, non-maleficence, and justice. The article proposes recommendations for mitigating these challenges, including community outreach, patient education, policy development, in-service education, and advocacy. While the legal requirements apply specifically to Florida and Texas, the ethical issues have nationwide relevance. (shrink)

Inequality is the defining feature of our times. Many argue that it calls for a policy response, yet the most obvious policy responses require legislative action. And if inequality is the defining feature of our times, partisan acrimony and gridlock are the defining features of the legislature. That being so, it is worth considering what role administrative agencies, and administrative law, might play in ameliorating or exacerbating economic inequality. Here, I focus on American safety net programs, many of (...) which are joint operations between federal administrative agencies and state governments. In this context, a central mode of bureaucratic policy innovation comes in the form of administrative waivers, whereby a federal administrative agency waives some statutory requirement that is otherwise binding on state administrators. For example, the Centers for Medicare and Medicaid Services recently granted waivers to allow several states to impose various “personal responsibility” requirements on Medicaid beneficiaries. Faced with a choice between legislative inactivity and policy innovation through waivers, many scholars and policymakers of both parties have tended to favor waivers. The appeal of waivers as a path around legislative gridlock is compelling. However, I argue that this view has neglected the federal structure of American safety net programs, and does not account for the state politics of implementation. Moreover, scholars have not focused on the severe information problems that federal agencies face when issuing waivers; a permissive waiver regime exacerbates these problems. Focusing on Medicaid implementation, I highlight the risks of waivers for American safety net programs. Before concluding, I discuss possible reforms to administrative procedures, and offer a case study of litigation surrounding one recent waiver application. The case study illustrates many of the theoretical arguments, and further demonstrates the failure of judicial review; it indicates how review might be adjusted to promote more effective use of waivers and diminish their perils. (shrink)

Advocates of culture-change management suggest that the right sort of managerial philosophy can transform nursing homes from impersonal institutions into safe, caring communities. However, participant observation carried out at Heartland Community, a nonprofit culture-change nursing home, suggests that culture change founders on the structural problem of inadequate staffing. Resource limitations imposed by Medicaid and Medicare reimbursement rates mean that even nonprofit facilities desiring to maximize staffing cannot afford to hire enough staff to live up to basic care standards. Thus, (...) above-average staffing notwithstanding, Heartland's nursing aides could not complete their work on time without compromising the quality of care by breaking important care rules. Resource limitations also forced management to adopt a series of punitive personnel policies that actively undercut the rhetoric and aims of culture change, turning culture change into a rhetorical device for shifting blame for care problems fromstructural resource limitations onto the attitudes of nursing aides. (shrink)

Presidential power has provoked increasingly vigorous debate since the turn of this century. In recent years, scholars and lawyers have been grappling with how Congress’s dictates may limit the president’s Commander-in-Chief power to detain enemy combatants at Guantanamo Bay, to fight wars abroad, and to conduct intelligence activities at home. But policymakers have not yet explored the many possibilities for invoking the president’s “Take Care” power to change health care policy.This article explores the scope and limits of President Barack (...) Obama’s ability to invoke his executive authority to reform health care. Specifically, it identifies ways the Obama Administration can use directives to: expand Medicaid and State Children’s Health Insurance Program coverage through section 1115 waivers; test quality initiatives through Medicare demonstration authority; expand health information technology; allow drug reimportation and experiment with contracting power under Medicare; enhance patient protections and private coverage requirements; lift coverage restrictions on Medicaid and SCHIP; and build on the health insurance program for federal employees. Consistent with the mission of the Legal Solutions in Health Reform project, this article does not endorse a particular policy. Instead of recommending “what,” it explains “how.”. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Journal of the History of Ideas 62.1 (2001) 59-79 [Access article in PDF] Money and Sovereignty in Early Modern France Jotham Parsons [The mint official] must above all seek integrity in the moneys, on which our features are imprinted and on which the general good depends. For what would be safe if our image were offended, and if that which a subject ought to venerate in his heart were (...) immediately violated by a sacrilegious hand? 1Early modern French commentators on money and monetary policy were fond of quoting this very late antique chancery formula; 2 it even appears in the epigraph to one unpublished commonplace book on the subject from the early seventeenth century. 3 Its popularity was no doubt due partly to the fact that classical literature contained few other theoretical statements on the practicalities of issuing money. 4 It also showed how deeply classical humanism had shaped economic thought, as it had done to all of French political culture. This was apparent as early as 1514 in Guillaume Budé's scholarly classic, De Asse et partibus ejus. 5 By 1600 these influences had ensconced themselves so firmly that economic writers found it nearly impossible to talk about money without a [End Page 59] full panoply of classical erudition. 6 In France the second half of the sixteenth century saw the rise of a specialized, expert, and increasingly systematic tradition of monetary thought. Despite its classical vocabulary, this economic literature was in many ways "modern" in its methods, ambitions, and subject. While developing an account which aspired to a scientific explanation of commercial society and of how government and money interacted, the French commentators came to a partial realization of how radically their own society differed from those which had gone before. In this respect the prevailing climate of thought about money influenced even a writer as non-technical as Michel de Montaigne.Traditionally, scholarly treatment of early modern French economic texts has focused on a relatively small range of issues and authors. One such issue, the origins of the "quantity theory of money" (with Jean Bodin as its hero), is notable for its sterility, since that concept was not and could not have been meaningful to contemporaries. 7 The origin and development of "mercantilism" or, more broadly, of "political economy" in general, has proven a more fruitful subject of inquiry. 8 Undeniably, the changing relationships among governments, merchants, and the economy were a major public issue and, in the seventeenth century, a major site of theoretical reflection on the nature of political power generally. Even so, an excessive concentration on mercantilism is dangerous, for however one defines it, it was not the first, and for a long time not the most significant, economic discourse in France. Rather, from the 1560s well into the seventeenth century, French discussions of economic issues centered on very concrete problems brought about by the government's obligation to issue and maintain a stable currency. 9 While one would search this literature in vain for the specific doctrines of modern economics, I argue that it did represent a real achievement in the early modern understanding of commerce and the state. Though they have not received their due from scholars, the writers who took part in these debates formed a large and influential school with close ties to the actual institutions of government. 10 The French monetary theorists did an enormous amount [End Page 60] to set the stage for the mercantilist era. They developed a detailed notion of monetary economics as a specialized discipline, and above all they placed money and economic policy in the context of a multi-national system of commercial states. In so doing, they sought to comprehend and control not just money but the modern state itself.Early modern money was perched uncomfortably between commodity and fiat. Bewildering varieties of coins circulated, composed of all sorts of alloys. The government assigned a face value for each coin which it authorized to circulate in the abstract accounting unit called the "money of account." 11 This value was almost always greater than... (shrink)

Those researching HIV prevention measures for people who inject drugs face a dilemma. Regions where baseline HIV prevalence and onward transmission via injecting is sufficiently high to power HIV prevention trials are also those where repressive laws, policies and practices raise concerns about the ethics of research subject protection. Dawson et al, outlining criteria to address ethical challenges in HIV prevention research among PWID, recommend that all trial participants be offered sterile injecting equipment and urge additional strategies to limit research (...) and background risks.1 In light of ethical questions opened by recent clinical trials involving PWID, including several the authors cite favourably, these cautions are timely. Dawson et al urge weighing of costs and benefits of PWID participation in research trials as an essential part of the ethical calculus. Overdose is a particular risk in any trial that uses abstinence from opioids as a precondition for participation or as an outcome of interest, and a risk that institutional review boards and researchers frequently ignore. Given the increased likelihood of fatal overdose for those who return to injection following a period of abstinence, provision to all trial participants of naloxone—the overdose antidote …. (shrink)

In 2014, the American Academy of Pediatrics published its policy statement on contraception for adolescents, which provides, in effect, a mandate to temporarily sterilize all adolescents with long-acting reversible contraceptives for five to ten years. The author reviews the AAP guidelines and their effects on Catholic adolescents, their families, and adolescent health care providers. He then discusses medicolegal issues raised by the policy, outlines Catholic strategies for combating it, and proposes a diocese-based physician-led program for teaching and counseling (...) elementary and high school students. (shrink)

The Oregon Health Plan gained national attention by changing the focus of health care from who is covered to what is covered. This change was facilitated by insurance reforms in the areas of small market, employer mandates, high risk pooling and Medicaid. Most controversial of the reforms is the use by the legislature of a prioritized list of health services to determine benefit levels for the insurance programs. Significant debate has occured over whether the use of such a list (...) is rationing or reasoning. The Oregon Health Plan represents a thoughtful and deliberate blending of fact with public value for the purpose of responsible health policy. It is that unique blending of public values developed through community participation with fact that focused the attention of the world on Oregon. Keywords: community participation, employer mandates, health care reform, prioritization, rationing, small market insurance reform CiteULike Connotea Del.icio.us What's this? (shrink)

Since the early 1970s, despite popular opposition, to control the rapid growth of population the Chinese government has been carrying out the strictest and most comprehensive family planning policy in the world. In addition to contraceptive methods and sterilization, artificial abortionhas been used as an important measure of birth control under the policy. Many women have been required, persuaded, and even forced by the authorities to abort fetuses no matter how much they want to give birth.

In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:Abortion to Abolition: Reproductive Health and Justice in Canada by Martha PaynterRebecca Simmons (bio)Abortion to Abolition: Reproductive Health and Justice in Canada by Martha Paynter Winnipeg, MB: Fernwood Publishing, 2022Martha Paynter's Abortion to Abolition: Reproductive Health and Justice in Canada is a bold, ambitious work that seeks to not only catalog Canada's meandering and often backtracking path toward reproductive justice, but to act as a manifesto for Paynter's (...) own ideas and goals for reproductive justice. The book takes the form of an anthology of stories, divided into chapters, that are grouped according to a certain right; for example, the right to bodily autonomy. This format effectively guides the reader from abortion to abolition. Paynter adroitly starts the book with white feminist favorites such as bodily autonomy and not having children. Then she logically progresses to more radical ideas such as parenting in prison and the total abolition of prisons. The stories in this book are accompanied by warm, colorful illustrations by Julia Hunt. These drawings help the reader visualize the person behind the story and the very real life that was affected by reproductive law and/or social norms. Paynter holds a PhD in nursing, and it is from this background that she writes, seeking to educate nurses and other healthcare professionals alongside a broader readership garnered through her clear, approachable writing style.Chapter 1 introduces the reader to many of the book's key themes by considering the right and need to have bodily autonomy, and the multiple ways this manifests itself in ordinary (and less-ordinary) life. Paynter considers the disparate stories of five women, all fighting in some way for bodily autonomy. The stories cover events of gender-based gun violence, sexual assault, transgender rights in prison, the legalization of sex work, police violence, and institutional racism. Each story recounted by Paynter catalogs tragedies and injustices with blunt and brutal honesty—perhaps to an unnecessary extent. Every horrific fact is laid bare for the readers as they uncover the intricacies of gender-based, imperialist, and racist violence. Paynter has chosen these stories to display the multitude of ways in which people—especially Black, Indigenous, people of color (BIPOC) and minoritized genders—can be willfully wronged by the state and [End Page 209] the criminal justice system, such that the reader must begin to confront the fact that these structures don't seem to exist to benefit or protect the most marginalized in society.Chapter 2 approaches the right not to have children through a number of stories related to contraception, abortion, and family planning. Paynter sketches some of the key points in Canada's journey toward the decriminalization of abortion, from paradoxical trailblazers, such as Dr. Emily Stowe in the 1800s, to the viral memefied content of art protestor iamkarats. While the unequivocal legality of abortion in Canada suggests incredible progressiveness and support for women's rights, Paynter paints a more complex picture through her chosen narratives. Crucially, the inequitable geographical access to abortion, in particular, throughout the huge landmass of Canada suggests that the right to not have children in Canada is not universal. Moreover, Paynter suggests that access is also bounded by financial constraints, finite public funding, and the limited availability of inclusive clinics that prioritize healthcare for LGBTQ2S+ people.Chapter 3 considers the topic of having children; in particular, the right to reproductive technologies and freedom from forced sterilization. Paynter quickly makes clear that while many white feminists might see having and not having children as diametrically opposed, they are two equally essential parts of reproductive justice. Paynter draws attention to the Sexual Sterilization Act of 1928 that was only overturned in 1972. She describes it as part of the "genocidal colonial project" (84), a collection of laws and policies aimed at fulfilling eugenicist, neoimperial ideals of increasing production of the white "race" and promoting the genocide of Indigenous peoples. Furthermore, Paynter argues that evidence of forced sterilization of Indigenous peoples, and other physical violence and neglect, persists to the present day and must be stopped and reparations made for previous harms. Paynter then considers the complex, often-debated case of commercialized surrogacy, which she defines... (shrink)

In 1995 the People's Republic of China passed a controversial Eugenics Law, which, after a torrent of international criticism, was euphemistically renamed the Maternal and Infant Health Law. Aimed at "the implementation of premarital medical checkups" to ensure that neither partner has any hereditary, venereal, reproductive, or mental disorders, the ordinance implies that those deemed "unsuitable for reproduction" should undergo sterilization or abortion or remain celibate in order to prevent "inferior births." Using this recent statute as a springboard, Frank (...) Dikötter explores the contexts and history of eugenics in both Communist China and Taiwan. Dikötter shows how beginning in Late Imperial China, Western eugenics was imported and combined with existing fears of cultural, racial, or biological degeneration in Chinese society, leading to government regulation of sexual reproduction. _Imperfect Conceptions_ is a revealing look at the cultural history of medical explanations of birth defects that demonstrates how Chinese assumptions about the relationship of the individual to society form the very core of their attitudes toward procreation. Dikötter explains the patrilineal model of descent, where a person is viewed as the culmination of his or her ancestors and is held responsible for the health of all future generations. By this logic, a pregnant woman's behavior and attitude directly influence the well-being of her baby, and a deformed or retarded child reflects a moral failing on the part of the parents. Dikötter also shows how the holistic medicine practiced in China blurs any distinction between individual and environment so that people are held responsible for illness. Drawing on cultural, social, economic, and political approaches, Dikötter goes beyond a simple authoritarian model to provide a more complex view of eugenic policy, showing how a variety of voices including those of popular journalists, social reformers, medical writers, sex educators, university professors, and politicians all disseminate information that supports rather than questions the state's program. _Imperfect Conceptions_ reveals how Chinese cultural currents--fear and fascination with the deviant and the urge to draw clear boundaries between the normal and the abnormal--have combined with medical discourse to form a program of eugenics that is viewed with alarm by the rest of the world. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Religious Perspectives on Bioethics, Part ILaura Jane Bishop (bio) and Mary Carrington Coutts (bio)This is Part One of a two part Scope Note on Religious Perspectives on Bioethics. Part Two will be published in the December 1994 issue of this Journal. This Scope Note has been organized in alphabetical order by the name of the religious tradition.Contents for Parts 1 and 2Part 1Part 2I.GeneralI.Native AmericanII.African Religious TraditionsReligious TraditionsIII.Bahá'í FaithII.Protestantism—willIV.Buddhism (...) and Confucianisminclude a general sectionV.Eastern Orthodoxyand sections focused onVI.Hinduismspecific denominations.VII.IslamIII.Roman CatholicismVIII.JainismIX.JudaismIntroductionThe many religions of the world bring diverse, and occasionally divergent, attitudes to bioethical issues. These beliefs may guide patients and health care professionals as they seek or provide health care. In an attempt to facilitate understanding of and access to information about these beliefs in our pluralistic and global society, this Scope Note identifies literature by the world's major religious groups on topics relating to bioethics.Topics covered by this Scope Note include general attitudes to health and [End Page 155] health care, the physician-patient relationship, treatment refusal, abortion, contraception, sterilization, reproductive technologies, genetics, mental health, human experimentation, organ transplantation and donation, death, euthanasia, suicide, and prolongation of life. Material was not available on all of these topics for each religion.The literature gathered here represents only a small portion of the available writing on religion and medicine, and is limited to that which comments explicitly on bioethical issues. Some faiths have a rich tradition of writing in bioethics; for others the literature is more limited. Variation in coverage is not intended to indicate the relative importance of a faith, but reflects accessibility and space constraints. Individuals interested in obtaining additional information are encouraged to contact the National Reference Center for Bioethics Literature.Specific citations about a region or country were chosen because of the predominance of a religious tradition within the population. In all cases, variation in spelling represents author usage. This Scope Note treats only the literature published in English, and every attempt has been made to identify English language sources for these faiths.It is important to remember that doctrinal and theological differences exist even within the same denomination and that views of individual patients, family members, and health care providers should be sought.Dictionaries and EncyclopediasMelton, J. Gordon, ed. Encyclopedia of American Religions. Fourth edition. Detroit: Gale Research, 1993. 1217 p. Basic information about the history, sacred texts, membership, educational facilities, publications, and North American addresses are provided for 1,730 churches, denominations, sects, and cults. Bibliographies for many faiths supplement this extensive resource.Reich, Warren T., ed. Encyclopedia of Bioethics. New York: Free Press, Macmillan, 1978. 4 volumes. Articles on all the major religions as they relate to bioethics are included in this highly-regarded encyclopedia. In addition, many of the topical essays feature a section on the views of various faiths on the topic under discussion. For the best use of the Encyclopedia, see the subject index in volume 4. (Note: a revised, second edition is due to be published by Macmillan in late 1994.)GeneralAmerican Psychiatric Association. Committee on Religion and Psychiatry. Guidelines Regarding Possible Conflict Between Psychiatrists' Religious Commitment and Psychiatric Practice. American Journal of Psychiatry 147 (4): 542, April 1990. The American Psychiatric Association recommends that psychiatrists respect their patients' religious beliefs and that they not impose their own [End Page 156] beliefs on their patients.Bankowski, Z., and Bryant, J. H. Health Policy, Ethics and Human Values: Proceedings of the XVIIth CIOMS Round Table Conference, Athens Greece. Geneva: Council for International Organizations of Medical Sciences, 1985. 336 p. Many sections of this volume address issues where religion impacts health policymaking. Africa, the Middle East, Europe, Latin America, and Asia are highlighted for the varied ways in which their religions and cultures are integrated into the provision of health care.Batchelor, Edward, ed. Abortion: The Moral Issues. New York: Pilgrim Press, 1982. 246 p. Batchelor compiles a collection of essays by experts on religious ethics as they relate to abortion. Includes... (shrink)

Recent anxieties about the deterioration of the global environment have had the effect of intensifying the ambiguity that surrounds the social roles of scientists and engineers. This has happened not merely, as suggested at the outset, because the environmental crisis has made their roles more conspicuous. Nor is it merely because recent disasters have alerted us to new, or hitherto unrecognized, social consequences of using the latest science-based technologies. What also requires recognition is that ideas about the social role of (...) modern science and engineering are embedded in, hence mediated by, larger views of the world. Within such American worldviews, moreover, the status of science and engineering is closely bound up with their perceived effect upon the environment.In the dominant culture, accordingly, the respect given to scientists and engineers is in large measure dependent on their ability to play the central role assigned to them in the historical narrative about progress. As the ostensible heroes of that popular story, they are expected to lead the way in realizing the promise of prosperity and general well-being. The environmental crisis surely has diminished the credibility of that story, thereby causing the social role of science and engineering to seem more dubious — more ambiguous. To be sure, the crisis also may have the effect, for very different reasons, of increasing the power and responsibility of organized science. But the late twentieth-century task of damage control cannot possibly elicit anything like the respect accorded to organized science by the earlier belief in progress.It also is important to recall, finally, that the narrative of progress itself has undergone a disillusioning transformation. The early Enlightenment version of the story depicted scientists and engineers working in the service of a social and political ideal that all people could share. But the later technocratic concept of progress, with its sterile instrumentalist notion of advancing the power of science-based technology as an end in itself, is far less likely to inspire trust. Its patent inadequacies have had the effect of enhancing the appeal, if only by contrast, of the seemingly “anti-science” ideologies of pastoralism and primitivism. All of which might be taken to suggest that if the scientific and engineering professions want to recover some of the respect and status they once had, they would be well advised to join with sympathetic humanists and social scientists in recuperating some of the idealism that the project of modern science formerly derived from its place within the ideology of progress. That might entail the sacrifice of their technocratic posture of neutrality, dissociating themselves from people and institutions responsible for environmental degradation, and their help in formulating a new concept — which is to say, new criteria — of progress to which they might commit themselves. A primary test of any proposed social policy under this new dispensation surely would be whether it would improve, or at a minimum protect, the life-enhancing capacities of the global ecosystem. *** DIRECT SUPPORT *** A8402064 00011 *** DIRECT SUPPORT *** A8402064 00012 *** DIRECT SUPPORT *** A8402064 00013. (shrink)

Just as physicians can object to providing services due to their ethical and/or religious beliefs, medical students can have conscience-based objections to participating in educational activities. In 1996, the Medical Student Section of the American Medical Association introduced a resolution calling on the AMA to adopt a policy in support of exemptions for students with ethical or religious objections. In that report, students identified abortion, sterilization, and procedures performed on animals as examples of activities that might prompt requests (...) for conscience-based exemptions. In response to the student initiative, the Council on Medical Education recommended the adoption of seven “principles to guide exemption of medical students from activities based on conscience.” The House of Delegates adopted these principles in their entirety. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:A Clear Division of Labor Within Environmental Philosophy?William M. Throop (bio)In discussions about the future of environmental philosophy, I have found myself supporting two positions that are in tension with one another. The first, which has been well explored in the last decade, is that environmental philosophy should have a more dramatic impact outside of academic circles. It should affect policy and guide the behavior of non-philosophers, which (...) usually requires that it deeply engage the empirical details of problems it addresses. The second is that environmental philosophy needs to improve its status within the larger philosophical community, which requires its practitioners to use methods that dominate mainstream philosophy and to be conversant with contemporary work in ethical theory, epistemology, metaphysics, and continental philosophy. Some have argued that this tension places a double burden on those training to be environmental philosophers; they must demonstrate both theoretical and practical excellence. I fear that such a standard will limit [End Page 147] the growth of environmental philosophy. It will be daunting to new environmental philosophers and achieved by only a few.With respect to this tension, I suggest that environmental philosophy should support a robust division of labor. Many new environmental philosophers should be recruited from cohorts trained primarily in core areas of philosophy. Most of these thinkers will probably focus on highly theoretical issues—issues that anyone in the field would recognize as philosophical.Their knowledge of environmental problems may be superficial and their audience likely will consist primarily of other philosophers. Their impact beyond philosophy may be quite limited (except for their students). I come from this tradition, and I am still delighted by the purely intellectual puzzles that our field generates. Work of this sort should be honored, but our field will be sterile if it is dominated by this kind of thought.I hope that many other new environmental philosophers will be trained in interdisciplinary environmental graduate programs or "applied" philosophy Ph.D. programs where they will acquire the interdisciplinary expertise necessary to address practical problems and to effectively engage non-philosophical audiences. This group of "practical" environmental philosophers should also include a host of practitioners in other fields who contribute to philosophical dialogue. I suspect that much work in this area will be case-based, empirically sophisticated and, where it addresses non-philosophical audiences, more reliant on compelling metaphors than on tight arguments. I doubt that it is fruitful to view this group as applying the work of the former group. The aims, the sources of insight and the standards of quality for the two groups are categorically different. For practical philosophers, the political feasibility of a proposal matters, and the arguments must have the capacity to move relevant stakeholders. The results of this work may appear to be philosophy-lite to those in the first group, but only if judged by standards that are inappropriate if we accept a division of labor in the field.This division of labor cannot be an apartheid. Many promising innovations in environmental philosophy will come from the interface between these groups. And unfortunately, a good bit of questionable work done in each group may result from a failure to understand progress that has been made by the other group. For example, philosophers focused only on theory may draw implications for action that fail to accord with current empirical information. Practical philosophers may [End Page 148] critique simplified metaethical positions that have long been abandoned in favor of more sophisticated versions. A healthy dialogue and a mutual respect should diminish these dangers. Such a division of labor has significant implications for graduate education, hiring and evaluation of faculty, and allocation of prestige within the field. The health and growth of environmental philosophy will depend on part on how we address these implications.William M. Throop Bill Throop is provost and professor of philosophy at Green Mountain College, an environmental liberal arts college in Poultney, VT. His background is in epistemology and philosophy of science, but in the last decade his work has focused on conceptual and ethical issues in ecological restoration and wilderness preservation. E-mail: [email protected] © 2007 Indiana University Press... (shrink)

Recent changes in access to contraceptive and infertility treatments in the state of Illinois, and across the United States more generally, have heightened class cleavages in access to reproductive health care benefits in the United States. Using data gleaned from government testimonies, public documents, and telephone interviews, the authors found that poor women have broad access to contraceptive coverage but very little access to infertility treatments, while working-and middle-class women have increasingly broad coverage of infertility treatments but spare coverage of (...) contraceptives. These findings suggest that while the extreme measures of the eugenics movement are less frequently in evidence, class differences in access to reproductive services lead to an equally dualistic, albeit unstated, fertility policy in the United States: encouraging births among working- and middle-class families and discouraging births among the poor, particularly those on Medicaid. (shrink)

During the past two decades, several reports have documented substantial support from clinicians, policy-makers, and the general public for the use of advance directives, yet studies continue to find that only a minority of individuals have completed these legal documents. Advance directives are written instructions, such as living wills or durable powers of attorney for health care, which describe an individual's medical treatment wishes in the event that individual becomes incapacitated in the future. The completion and use of advance (...) directives is one of several components of the broader activity of advance care planning, that is, the overall planning and communication of personal wishes concerning future medical care.In December 1991, the federal Patient Self-Determination Act became effective. Promoted as a federal initiative to enhance an individual's control over medical treatment decision making and, therefore, patient autonomy and self-determination, PSDA placed several new requirements on health care organizations receiving Medicare or Medicaid payments. (shrink)