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Bioethics

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Reflections on Health and Beneficence

Definitions of health and disease are of more than theoretical interest. Understanding what it means to be healthy has implications for choices in medical treatment, for ethically sound informed consent, and for accurate assessment of policies or programs. This deeper understanding can help us create more effective public policy for health and medicine. It is notable that such contentious legal initiatives as the Americans with Disability Act and the Patients' Bill of Rights fail to define adequately the medical terms on which their effectiveness depends. In Ethics and the Metaphysics of Medicine, Kenneth Richman develops an "embedded instrumentalist" theory of health and applies it to practical problems in health care and medicine, addressing topics that range from the philosophy of science to knee surgery.

"Embedded instrumentalist" theories hold that health is a match between one's goals and one's ability to reach those goals, and that the relevant goals may vary from individual to individual. This captures the normative implications of the term health while avoiding problematic relativism. Richman's embedded instrumentalism differs from other theories of health in drawing a distinction between the health of individuals as biological organisms and the health of individuals as moral agents. This distinction illuminates many difficulties in patient-provider communication and helps us understand conflicts between promoting health and promoting ethically permissible behavior. After exploring, expanding, and defending this theory in the first part of the book, Richman examines its ethical implications, discussing such concerns as the connection between medical beneficence and respect for autonomy, patient-provider communication, living wills, and clinical education.

Medical Underwriting and Social Policy

Insurance companies routinely use an individual's medical history and family medical history in determining eligibility for life insurance; this is part of the process of medical underwriting. Insurers have also long used genetic information, often derived from family history, in underwriting. But rapid advances in gene identification and genetic testing are changing the way we look at genetic information. Should the results of genetic testing (which might identify a predisposition toward disease not related to medical history) be available to life insurance medical underwriters? Few if any life insurers currently require genetic testing, but there are no laws or regulations prohibiting its use. Genetics and Life Insurance examines the complex economic, legal, and social issues surrounding the use of genetic information in life insurance underwriting. The contributors are legal scholars, representatives of the life insurance industry (including an actuary and an insurance physician), a geneticist, a genetic counselor, a philosopher, and a consumer advocate. They explore all aspects of an issue that has only recently drawn the attention of policymakers and the public.

The book opens with a report on the results of a public opinion poll on genetics and life insurance. Succeeding chapters present the insurer perspective, a discussion of the economics of risk selection in life insurance, background information on the process of underwriting, a scientific analysis of genetic risks and mortality rates, a philosophical discussion of fairness and genetic underwriting, the viewpoints of consumers and genetics counselors, a comparison of different international policy approaches to the issue, and a legal analysis of antitrust implications when insurers collaborate in setting standards for medical underwriting. In the final chapter the editor addresses various policy options, examining the pros and cons of each one and assessing their political feasibility.

Medicine and Morality in a Time of Crisis

The war on terrorism and the threat of chemical and biological weapons have brought a new urgency to already complex moral and bioethical questions. In the Wake of Terror presents thought-provoking essays on many of the troubling issues facing American society, written by experts from the fields of medicine, health care policy, law, political science, history, philosophy, and theology.

One of the first potential casualties of catastrophic circumstances is civil liberties. In the past, medical experiments conducted for national security purposes have violated ethical standards, and this book questions whether current policy provides sufficient safeguards against further abuses. It also focuses on public health issues, offering contrasting views on the extent to which civil authorities should be allowed to restrict freedom of movement in the name of national security and debating whether aggressive public health interventions improve public confidence and cooperation or detract from them.

A major area of concern is preparedness for future terrorist attacks. Chapters are devoted to ethical issues involved in the development, distribution, and rationing of vaccines and antidotes; resource allocation and medical triage; the moral duties of emergency health workers and other first responders; and the obligations of private entities such as managed care organizations and pharmaceutical companies. Contributors also address the implications of terrorism for our health insurance system and the role of genetic advances in bioterrorism. Underlying all of these issues, the authors argue, is the need to maintain a spirit of social solidarity, which can in turn only be achieved if preparations are publicly acknowledged and generally regarded as both prudent and fair.

Contributors: George Annas, Ronald Bayer, James Childress, James Colgrove, Evan DeRenzo, Lisa Eckenwiler, Alan R. Fleischman, Lawrence O. Gostin, James G. Hodge, Jr., Kenneth Kipnis, Paul Lombardo, Eric Meslin, Ann Mills, Jonathan D. Moreno, Griffin Trotter, Patricia Werhane, Emily Wood.

This textbook for instruction in biomedical research ethics can also serve as a valuable reference for professionals in the field of bioethics. The 149 cases included in the book are grouped in nine chapters, each of which covers a key area of debate in the field. Some of the case studies are classics, including the famous cases of the Tuskegee Syphilis Study (in which subjects with syphilis were not given treatment) and the Willowbrook hepatitis studies (in which institutionalized subjects were intentionally exposed to hepatitis). Others focus on such current issues as human embryonic stem cell research, cloning by somatic nuclear transfer, and the design and function of institutional review boards. Each chapter begins with a brief introduction that places the issues raised in context; this is followed by a number of cases (each of which is no more than a few pages). Study questions meant to encourage further discussion follow each case.

After an introductory discussion of the history and tenets of ethics in medical research, the book's chapters cover the topics of oversight and study design; informed consent; the selection of subjects; conflicts of interest; the social effects of research; embryos, fetuses, and children; genetic research; the use of animals; and authorship and publication. Following these chapters are appendixes with the texts of the Nuremburg Code and the World Declaration of Geneva, two key documents in the establishment of bioethical standards for research. Also included are a glossary, a table of cases by general category, and an alphabetical listing of cases.

The idea of the gene has been a central organizing theme in contemporary biology, and the Human Genome project and biotechnological advances have put the gene in the media spotlight. In this book Lenny Moss reconstructs the history of the gene concept, placing it in the context of the perennial interplay between theories of preformationism and theories of epigenesis. He finds that there are not one, but two, fundamental—and fundamentally different—senses of "the gene" in scientific use—one the heir to preformationism and the other the heir to epigenesis. "Gene-P", the preformationist gene concept, serves as an instrumental predictor of phenotypic outcomes, while "Gene-D", the gene of epigenesis, is a developmental resource that specifies possible amino acid sequences for proteins. Moss argues that the popular idea that genes constitute blueprints for organisms is the result of an unwarranted conflation of these independently valid senses of the gene, and he analyzes the rhetorical basis of this conflation.

In the heart of the book, Moss uses the Gene-D/Gene-P distinction to examine the real basis of biological order and of the pathological loss of order in cancer. He provides a detailed analysis of the "order-from-order" role of cell membranes and compartmentalization and considers dynamic approaches to biological order such as that of Stuart Kauffman. He reviews the history of cancer research with an emphasis on the oncogene and tumor suppressor gene models and shows how these gene-centered strategies point back to the significance of higher level, multi-cellular organizational fields in the onset and progression of cancer. Finally, Moss draws on the findings of the Human Genome Project, biological modularity, and the growing interest in resynthesyzing theories of evolution and development to look beyond the "century of the gene" toward a rebirth of biological understanding.

Edited by Glenn McGee

Modern scientific and medical advances bring new complexity and urgency to ethical issues in health care and biomedical research. This book applies the American philosophical theory of pragmatism to such bioethics. Critics of pragmatism argue that it lacks a universal moral foundation. Yet it is this very lack of a metaphysical dividing line between facts and values that makes pragmatism such a rigorous and appropriate method for solving problems in bioethics. For pragmatism, ethics is a way of satisfying the complex demands of multiple individuals and groups in a contingent and changing world. Pragmatism also demands careful attention to the ways in which scientific advances change our values and ethics.The essays in this book present different approaches to pragmatism and different ways of applying pragmatism to scientific and medical matters. They use pragmatism to guide thinking about such timely topics as stem cell research, human cloning, genetic testing, human enhancement, and care for the poor and aging. This new edition contains three new chapters, on difficulties with applying pragmatism to law and bioethics, on helping people to die, and on embryonic stem cell research.

The Unspoken Dimensions of Environmental Concern

Virtually everyone values some aspect of the natural world. Yet many people are surprisingly unconcerned about environmental issues, treating them as the province of special interest groups. Seeking to understand how our appreciation for the beauty of nature and our indifference to its destruction can coexist in us, Shierry Weber Nicholsen explores dimensions of our emotional experience with the natural world that are so deep and painful that they often remain unspoken.

The Love of Nature and the End of the World is a gathering of meditations and collages. Its evocations of our emotional attachment to the natural world and the emotional impact of environmental deterioration are meant to encourage individual and collective reflection on a difficult dilemma. Nicholsen draws on work in environmental philosophy and ecopsychology; the writings of psychoanalytic thinkers such as Wilfred Bion, Donald Meltzer, and D. W. Winnicott; and ideas from Buddhist and Sufi traditions. She shows how our emotional responses to the vulnerabilities of the natural world range from intense caring and compassion, through grief and outrage, to diffuse depression. Individual chapters focus on silence and the process whereby we move from the unspoken to the spoken, the love of nature, the "perceptual reciprocity" with the natural world to which we might mature, beauty in the human and natural realms, the psychological impact of the destruction of the natural world, and reflections on the future.

Learning to Perceive Global Environmental Change

This book shows how to make global environmental problems more tangible, so that they become an integral part of everyday awareness. At its core is a simple assumption: that the best way to learn to perceive the biosphere is to pay close attention to our immediate surroundings. Through local natural history observations, imagination and memory, and spiritual contemplation, we develop a place-based environmental view that can be expanded to encompass the biosphere.

Interweaving global change science, personal narrative, and commentary on a wide range of scientific and literary works, the book explores both the ecological and existential aspects of urgent issues such as the loss of biodiversity and global climate change. Written in a warm, engaging style, Bringing the Biosphere Home considers the perceptual connections between the local and global, how the ecological news of the community is of interest to the world, and how the global movement of people, species, and weather systems affects the local community. It shows how global environmental change can become the province of numerous educational initiatives—from the classroom to the Internet, from community forums to international conferences, from the backyard to the biosphere. It explains important scientific concepts in clear, nontechnical language and provides dozens of ideas for learning how to practice biospheric perception.

The United States Social Security fund is huge and in trouble. The United Kingdom has experimented with the voluntary contracting out of pensions to the private sector. Chile has privatized its public pension system. Australia has adopted a means-tested public pension system. Japan has the earliest retirement age of any advanced economy; it also has the highest rate of labor force participation by elderly men. Can We Afford to Grow Older? provides a comprehensive, up-to-date survey of the implications of population aging in these and other OECD countries relative to a range of specific interrelated issues—Social Security schemes, employer pensions, educational attainment, wage growth and distribution, economic productivity, consumption, savings, retirement, and health care—all within a realistic framework for modeling and discussing policy. International in scope, filled with rich institutional detail, and built on a solid technical foundation, this will be a standard reference on the economic consequences of aging.

Richard Disney adopts a "life-cycle" view of the world which recognizes that individuals often make plans with a forward-looking perspective across the stages of childhood, the peak of economic productivity, and retirement. He stresses the existence of overlapping generations and the reality of generational transactions (which include tax and transfer systems, bequests, and charity to the elderly). And he assumes intertemporal optimization as a useful unifying basis for analyzing social security, private pension schemes, lifetime labor-supply decisions, consumption, and saving.

Among the surprising conclusions that emerge is that there is no "crisis of aging"—no adverse effect of aging on productivity. And although there are serious crises in pay-as-you-go social insurance programs and in health care, these have little to do with aging. Moreover, the shift in private provision plans away from traditional defined- benefit plans will continue, along with an interest in privatized pensions instead of social security.

Philosophical Psychopathology is a benchmark volume for an emerging field where mental disorders serve as the springboard for philosophical insights. It brings together innovative, current research by Owen Flanagan, Robert Gordon, Robert Van Gulick, and others on mental disorders of consciousness, self-consciousness, emotions, personality, and action and belief as well as general methodological questions about the study of mental disorder. Topics include the problem of despair, multiple personality disorder, autism and the theory of the mind debate, and the effectiveness of psychotherapy.An extensive introduction shows how to interpret philosophical psychopathology as an interdisciplinary field and locates the contributions in the book conceptually and in terms of the surrounding literature.Psychopathology promises to clarify and illuminate a host of philosophical issues. The twelve chapters focus chiefly on issues in applied philosophy of mind (personal identity and self- consciousness, voluntary action and self-control, cognition and practical reasoning), in the science of mind (the medical model of mental disorders, philosophy of science and psychiatry, psychopathology and folk psychology), and in the ethical and experiential dimensions of psychopathology.A Bradford Book

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