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Justice, Society, Physicians and Ethics Committees: Incorporating Ideas of Justice Into Patient Care Decisions

Published online by Cambridge University Press:  29 July 2009

Erich H. Loewy
Erich H. Loewy
Affiliation:
Professor and Alumni Chair of Bioethics at University of California, Davis.
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Extract

Issues of social justice have traditionally been given short shrift by American healthcare professionals, feeling that justice at the bedside is inapplicable and possibly even misplaced. However, perhaps motivated by the realization that escalating costs and maldistribution of healthcare represent an intolerable situation, an ever-growing amount of medical literature and healthcare ethics literature is turning to considerations of justice.

Type
Articles
Information
Cambridge Quarterly of Healthcare Ethics , Volume 5 , Issue 4 , Fall 1996 , pp. 559 - 569
Copyright
Copyright © Cambridge University Press 1996

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References

Notes

1. When Professor Cassell argues that justice has no place at the bedside I think that he sees ‘;justice’ as being entirely impersonal. I do not at all dispute Cassell's claim that an impersonal justice is incompatible, indeed that it is inimical to the healthcare professional patient relationship as we understand it. See Cassell, E. Do justice, love mercy: The inappropriateness of the concept of justice applied to bedside conditions. In: Shelp, EE, Ed. Justice and Health Care. Dordrecht: Reidel D, 1981:75–82. My argument rather is that the operative (as perhaps distinct from the purely formal or abstract) concept of justice must include all facts relevant to the case and, therefore, must perforce include features of personal obligation and compassion.CrossRefGoogle Scholar

2. Using the capacity to suffer as at least one of the criteria for giving something moral standing has been proposed in several books and papers. Among others see Loewy, EH. Suffering and the Beneficent Community: Beyond Libertarianism. Albany, NY: State University of New York Press, 1991.Google Scholar

3. The contrast between generosity and justice has often been noted. A supposed contrast between compassion and justice may be believed to follow but does not necessarily do so. Generosity is a supererogatory act. Compassion, on the other hand, in its inception is a natural drive and can (but need not) serve as a motivator for generosity.

4. See Engelhardt, HT. Bioethics and Secular Humanism: The Search for a Common Morality. Philadelphia: Trinity Press International, 1991.Google Scholar The philosophy that underpins libertarianism has a long history. In its modern clothes perhaps its most significant proponent is Professor Nozick. (See Nozick, H. Anarchy, State and Utopia. New York: Basic Books, 1974).Google Scholar In healthcare ethics a very similar type of world-view can be found underwriting the works of Professor Engelhardt. (See Engelhardt, HT. The Foundations of Bioethics. New York: Oxford University Press, 1986). It is, of course, a point of view that is basic to capitalism in its crassest forms.Google ScholarPubMed

5. Translated into healthcare ethics, such a viewpoint makes of medicine a pure business, run by contract between healthcare professionals and their customers. The market controls. See Engelhardt, HT. Health care allocations: response to the unjust, the unfortunate and the undesirable. In: Shelp, EE, Ed. Dordrecht, , Reidel, D; 1981;Google Scholar as well as Engelhardt, HT: Morality for the medicalindustrial complex: a code of ethics for the mass-marketing of healthcare. New England Journal Medicine 1988; 319:1086–9. Here is not the place to examine some of the dubious aspects of these claims. Even if one were to grant the libertarian premise—which I am far from doing—one is still left with the troubling question of what “standing in one's way” means. The argument that being poor (or ill, or ugly) is merely unfortunate but not unjust is, in my view, difficult to maintain in a complex society which has structured itself in ways which produce poverty in many and extreme wealth in some few.CrossRefGoogle Scholar

6. Hobbes, T. Leviathan. New York: Collier Books, 1962:113.Google Scholar

7. Note 6. Hobbes, 1962:255.Google Scholar

8. Note 6. Hobbes, 1962:255.Google Scholar

9. Cole, GD. Preface. In: Rousseau, JJ, Ed. The Social Contract and the Discourses. (Trans, Cole, GDH) New York: Everyman's Library, 1993: 383–4.Google Scholar

10. Cole, GD. Preface. In: Rousseau, JJ. The Social Contract and the Discourses. (Trans. Cole, GDH). New York: Everyman's Library 1993:383–4.Google Scholar

11. Rousseau, JJ. A Discourse on the Origins of Inequality.Google Scholar See note 10. Rousseau, 1993:75.Google Scholar

12. See note 10. Rousseau, 1993:73.Google Scholar

13. See note 10. Rousseau, 1993:383–4.Google Scholar

14. See note 10. Rousseau, 1993:190.Google Scholar

15. Cassirer, E. Rousseau, Kant und Goethe. Hamburg: Meiner Verlag, 1991.Google Scholar

16. See note 10. Rousseau, 1993:385.Google Scholar

17. John Dewey's point of view has to be understood in the context of his entire philosophy. It is an insistence that dissociating theory and praxis makes little sense. Ethics—like all else—is developed by inquiry that in its methodology does not differ from the scientific method in general. Propositions are tested in praxis, are never fully developed, and are always in the process of being. One cannot truly solve a problem; one can merely make an “indeterminate situation more determinate,” and this determinacy is merely a new indeterminacy to be further worked upon. Such working out of problems occurs best in a well-functioning and truly democratic community. See, among others, Dewey, J. Ethics. In: Boydston, JA, Kolojeski, PJ, Eds. John Dewey: The middle works 1899–1924, Vol. 5. Carbondale: Southern Illinois University Press, 1988:Google ScholarDewey, J. The public and its problems. In: Boydston, JA, Walsh, BA, Eds. John Dewey: The Later Works 1925–1953. Carbondale, Illinois: Southern Illinois University Press, 1988:Google Scholar

18. The works of John Rawls are central to any discussion of justice and have been most influential in the development of policy. See Rawls, J. A Theory of Justice. Cambridge, Massachusetts: Harvard University Press, 1971.Google Scholar

19. The link (rather than the tension) between individual aspirations for freedom and the preservation of community and attention to communal needs (seeing this relationship as homeostatic and not as dialectic) was first suggested in my book Freedom and Community. (See Loewy, EH. Freedom and Community: The Ethics of Interdependence. Albany, N.Y.: State University of NY Press, 1993)Google Scholar and is being further developed in my forthcoming Moral Strangers, Loewy, EH. Moral Strangers, Moral Acquaintance and Moral Friends: Interconnectedness and Its Conditions. Albany, N.Y.: State University of New York Press, 1996.Google Scholar

20. The concept of a framework of common human capacities and experience to serve as a framework for working out an ethic is proposed in the forthcoming Moral Strangers. See note 19. Loewy, 1996.Google Scholar

21. Kant, I. Critique of Pure Reason (Trans, Smith, NK) New York: St. Martin's Press, 1965.Google Scholar

22. Loewy, EH. Compassion, reason and moral judgment. Cambridge Quarterly of Healthcare Ethics 1995; 4:466–75.CrossRefGoogle ScholarPubMed

23. See note 19. Loewy, 1996.Google Scholar