I. INTRODUCTION The Medicare program, it is quite often asserted, is special for Canadians becaus... more I. INTRODUCTION The Medicare program, it is quite often asserted, is special for Canadians because the program is taken to embody something distinctive and superior about Canadian social values. For some Canadians, it follows that any effort to alter Medicare substantially amounts to an attack on Canadian values and should be rejected. On the other hand, others have claimed that Canadian national values have undergone substantial changes, and that this shift in values may justify (or excuse) amendments and alterations to the Medicare program. These are what we will term anti- and pro-amendment positions. Both assume a fairly tight connection between what are called "Canadian national values" and the particular structural features of Medicare. In light of this ongoing debate, we have been asked by the Romanow Commission to investigate the role of "national values" in the shaping (or re-shaping) of health insurance programs in Canada, and more generally in the world of developed democracies. Section II is first a methodological commentary on what is and can sensibly be meant by appeals to "national values." It then addresses the general theoretical concerns about how such values might be embodied in the institutions of different Western democracies. Section III begins by taking note of the large number of reports that have recently called for reform of the Canadian health care system. After commenting briefly on the relevance of the value presumptions of these reports for this inquiry, we approach our central topic in Section IV. That part of the paper provides some comparative evidence that shows how loose the connections really are between anything coherently termed "national values" and the concrete forms of social institutions. Many variables besides "values" are at work in shaping and re-shaping particular institutions of social policy, we argue. And, conversely, we claim, many quite differently shaped social institutions may reasonably be said to embody the same set of values. In Section V, w e return to the Canadian discussion of Medicare, and argue that a range of possible amendments would be perfectly consistent with -- and therefore would be not greatly threaten -- Canadian social values. Choosing among those options requires a degree of prudence -- an attention to the political realities of conflicting interests, and to the practical realities of resource management and information -- at least as important as the values that prudence aims to advance. That a social welfare institution expresses the right values is a necessary, but is not a sufficient, basis for its adoption as a wise course of action. Section VI concludes. II. WHAT ARE "NATIONAL VALUES"? THE PRESUMPTIONS OF THE INQUIRY After all, values are held by persons, not by corporate entities that have neither minds nor desires. It is true that we may speak loosely of the "values of the common law," or the "values of the Catholic church." By such usage we mean to locate fundamental doctrines that emerge from the writings, or from the beliefs of the elite, within a certain tradition. But in general, "values" refers to subjective views of individuals about what is worthy or important. In politics, these are views about the ends that social institutions ought to advance, and the virtues they ought to embody. One's values are general; they do not dictate preferences for particular institutional structures at any level of detail (Rawls 1971). That one values privacy in health care need not lead one, for example, to endorse a particular set of detailed privacy rules (those contained in the new United States Health Insurance Portability and Accountability Act of 1996 [HIPAA] regulations, say). It leads one only to prefer institutional arrangements that protect privacy over those that do not, and arrangements that protect privacy more over those that protect it less. …
Some people with dementia are transformed by the disease, to the point that family members may de... more Some people with dementia are transformed by the disease, to the point that family members may describe them as a "different person." These transformations may be negative or positive. What factors affect the judgements of ordinary people about whether an advance directive (AD) should be followed in such cases? We conducted three studies to test the influence of (1) positive versus negative transformation and (2) "treat" versus "withhold treatment" AD on the judgements of US participants (n = 1676) as to whether the AD should be followed and the extent to which the late-stage dementia patient had become a different person. We found that participants generally endorsed following the AD, irrespective of condition, but much less so when the patient had a positive transformation. Participants also favored "treat" over "withhold treatment" ADs. Unexpectedly, we found that AD type affected "different person" judgments: participants registered significantly weaker agreement with the proposition that the patient had become a different person when the AD instructed treatment. We discuss these results in the context of Walsh's (2020) newly proposed normative model for AD decision-making.
There are at present two conflicting images of Canada's Medicare available to observant adult... more There are at present two conflicting images of Canada's Medicare available to observant adults in the United States. One is the conventional media portrait of crisis--from both U.S. and Canadian sources--an image of a program in deep trouble, overcome by problems of access, cost, and quality. The other image is far more favorable: Canadian Medicare as an structurally sound program of universal health insurance that largely satisfies those who use it, but, like all programs, requires managerial adjustment and attention to the fearfulness of Medicare's future that has marked the last decade. This was the conclusion of the report of the Canadian Institute for Health Information (CIHI) in 2000. Both portraits cannot be accurate, just as being green and white all over is logically impossible. What is the American interpreter to make of this dispute? I. THE EMERGENCY ROOM STORY: A Similar Tale with Two Meanings One place to begin is the crowded state of the North American emergency room (ER), a familiar story in both Canada and the United States over the past decade. When the winter's flu season of 2000 aggravated overcrowding in North American ERs, the U.S. (and Canadian) media took special notice. That winter The Washington Post, The New York Times, and ABC News did stories on the quality of emergency rooms in Canada. (This paralleled Canadian media treatment and in fact amplified those stories). During the same period, USA Today and Time published substantial reports on U.S. emergency rooms. But there was a distinct difference in the stories told. The three reports on Canada used the overcrowding problem to suggest Medicare is critically flawed. The two extended reports on American overcrowding did not, by contrast, indict America's overall health insurance arrangements. The similarity of the North American stories was, however, quite striking. USA Today reported that "for nearly 10 days in December of 1999, "60 of 81 [Los Angeles] hospitals were so full that hospital administrators asked to send ambulances elsewhere." The same newspaper cited a California woman who died in an ambulance awaiting hospital admission. The journalistic portrait of Canadian ERs cited similar experiences. In Toronto, overcrowding was so serious that the New York Times reported "23 of the city's hospitals [had] to turn away ambulances." ABC News cited an asthma patient who died in an ambulance that had been diverted from the nearest hospital. The important point is not the parallel reports but the different interpretations placed on them. The stories about U.S. conditions attributed the problem in part to the flu, while the reports about Canadian ERs either ignored the flu or dismissed it as an attempt by Canadian public officials to put a happy face on a Medicare in crisis. Steven Pearlstein of The Washington Post asserted that "most experts" agree that Canada's Medicare is doomed, that "while money might alleviate the shortage of advanced machinery, hospital beds, and medical school slots, it will only be a matter of time before the demand for medical services once again overtakes the willingness of voters to pay for it." (Reader's alert: most experts actually know that the demand for medical care is practically limitless and distinguish demand from serious needs. The claim of critical shortages appears universally in systems of "single-pipe financing" of health insurance. This phenomenon, called 'orchestrated outrage', is a familiar bargaining ploy which may, or may not, indicate worrisome medical circumstances. To conclude circumstances are dire requires evidence other than claims of shortage, as every national health insurance official in the Western world knows.) What the U.S. media portrayed as programmatic failure was both a reflection and an amplification of the Canadian emergency room stories. Indeed most Canadian papers got at least a month's solid copy out of hospital overcrowding, the turning away of patients from emergency rooms, and the deaths of individual patients unable to get emergency treatment. …
1. Am J Bioeth. 2006 May-Jun;6(3):56-8; discussion W51-3. Some limits of decision-theory in bioet... more 1. Am J Bioeth. 2006 May-Jun;6(3):56-8; discussion W51-3. Some limits of decision-theory in bioethics: rights, ends, and thick concepts. Latham SR. School of Law, Quinnipiac University. Comment on: Am J Bioeth. 2006 May-Jun;6(3):46-52. ...
This article offers some general criticisms of the idea that any political theory can legitimate ... more This article offers some general criticisms of the idea that any political theory can legitimate public health interventions, and then some particular criticisms of Civic Republicanism as a political theory for public health. Civic Republicanism, I argue, legitimizes liberty-infringing public health interventions by demanding high levels of civic engagement in framing and reviewing them; to demand such engagement in pursuit of such a baseline value as health will leave insufficient civic energy for the pursuit of higher values.
Reading a book is also kind of better solution when you have no enough money or time to get your ... more Reading a book is also kind of better solution when you have no enough money or time to get your own adventure. This is one of the reasons we show the conflicts of interest and the future of medicine the united states france and japan as your friend in spending the time. For more representative collections, this book not only offers it's strategically book resource. It can be a good friend, really good friend with much knowledge.
The coronavirus disease-2019 (COVID-19) has caused shortages of life-sustaining medical resources... more The coronavirus disease-2019 (COVID-19) has caused shortages of life-sustaining medical resources, and future waves of the virus may cause further scarcity. The Yale New Haven Health System developed a triage protocol to allocate scarce medical resources during the COVID-19 pandemic, with the primary goal of saving the most lives possible, and a secondary goal of making triage assessments and decisions consistent, transparent, and fair. We outline the process of developing the triage protocol, summarize the protocol itself, and discuss the major ethical challenges encountered, along with our answers to these challenges. These challenges include (1) the role of age and chronic comorbidities; (2) evaluating children and pregnant patients; (3) racial, ethnic, and socioeconomic disparities in health; (4) prioritization of healthcare workers; and (5) balancing clinical judgment versus protocolized assessments. We conclude with a review of the limitations of our protocol and the lessons learned. We hope that a robust public discussion of such protocols and the ethical challenges that they raise will result in the fairest possible processes, less need for triage, and more lives saved during future waves of the COVID-19 pandemic and similar public health emergencies.
Crisis standards of care have been widely developed by healthcare systems and states in the Unite... more Crisis standards of care have been widely developed by healthcare systems and states in the United States during the COVID-19 pandemic, and in some rare cases have actually been used to allocate medical resources. All publicly available U.S. crisis standards of care with a mechanism for allocating scarce resources make use of the Sequential Organ Failure Assessment (SOFA) score in hopes of assigning scarce resources to those patients who are more likely to survive. We reflect on the growing body of evidence suggesting that the SOFA score has limited accuracy in predicting mortality among patients hospitalized with COVID-19 and that the SOFA score systematically disfavors Black patients. Use of the SOFA score for allocating scarce resources may therefore result in Black patients with equal likelihood of survival being deprived of life-saving medical resources. There is also a risk of injustice for patients with non-COVID-19 diagnoses, for whom the SOFA score may be a more accurate prognostic score, but who might nevertheless be unfairly (de)prioritized when assessed alongside COVID-19 patients using the same scoring system. For these reasons we recommend that the SOFA score not be used for triage purposes during the COVID pandemic, and that a national effort be made to develop and empirically test crisis standards of care in advance of the next public health emergency.
We welcome and applaud Wilkinson’s (2021) impressive and subtle exploration of the possible (legi... more We welcome and applaud Wilkinson’s (2021) impressive and subtle exploration of the possible (legitimate and illegitimate) considerations of frailty as a criterion for triage in times of pandemic-driven scarcity of Intensive Care Unit (ICU) resources. To his analysis we wish to add some consideration of the consequences, for triage decisions, of the fact that frailty is sometimes reversible; some consideration of the need for additional research into the younger frail; and along the way, some views about legitimate criteria for rationing at all. Let us begin with praise. As a preliminary matter, Wilkinson has helpfully pointed out the importance of considering frailty in shared decision making, and its arguable irrelevance to always-difficult arguments about medical futility. Empirically, he has shown its relevance to calculations about survival-to-discharge, its relevance to calculations about probable longevity, its relevance to controversial arguments about quality of life, its separability from age-based rationing, and its lack of proven correlation with considerations of length of ICU stay. Procedurally, he has argued for three features of any scheme that might permissibly include consideration of frailty in determining priority of access to limited ICU resources: that the consideration of frailty be explicit; that its use be consistent across patients; and that considerations of frailty also be consistent, within any triage framework, with other considerations of other medical conditions that support similar reasons for affecting priority of access to limited ICU resources (“triage equivalence”). We applaud and welcome this contribution. Wilkinson’s substantive arguments about the use of frailty in rationing are also quite illuminating and helpful. He notes, for example, that many of the superficial criteria for frailty could misleadingly be applied to people with chronic mobility disorders and other stable chronic disabilities. He points out, also, that when frailty is introduced into triage discussions as a proxy for quality-of-life, the danger of “ableism” or disability discrimination is more difficult to avoid. Quality of life is highly subjective in nature and efforts to standardize medical judgments about it (such as QALY) are notoriously flawed. It is wellknown, for example, that persons who become disabled accept and embrace as high-quality, lives with disability that they would have rejected when they were able-bodied. Both judgments about quality of life, and judgements about tradeoffs between quality and quantity of life, are notoriously difficult to measure. Thus far we agree with Wilkinson. Where we begin to want to modify his arguments, though, is where he discusses the relationship of frailty to agediscrimination. It is certainly true that using frailty as a proxy for life-expectancy partakes less in age-discrimination than does using straight-up age. Our objection is first, to the consideration of lifeexpectancy (conceived as life-years saved) in rationing at all; and second, to the pessimistic use of a potentially-reversible condition to deny lifesaving care.
Guidelines for national human immunodeficiency virus case surveillance, including monitoring for ... more Guidelines for national human immunodeficiency virus case surveillance, including monitoring for human immunodeficiency virus infection and acquired immunodeficiency syndrome. MMWR Recommendations and Reports 48(RR13): 1-28. Molldrem, S., and A. K J Smith. 2020. Reassessing the ethics of molecular HIV surveillance in the era of cluster detection and response: Toward HIV data justice. The
I. INTRODUCTION The Medicare program, it is quite often asserted, is special for Canadians becaus... more I. INTRODUCTION The Medicare program, it is quite often asserted, is special for Canadians because the program is taken to embody something distinctive and superior about Canadian social values. For some Canadians, it follows that any effort to alter Medicare substantially amounts to an attack on Canadian values and should be rejected. On the other hand, others have claimed that Canadian national values have undergone substantial changes, and that this shift in values may justify (or excuse) amendments and alterations to the Medicare program. These are what we will term anti- and pro-amendment positions. Both assume a fairly tight connection between what are called "Canadian national values" and the particular structural features of Medicare. In light of this ongoing debate, we have been asked by the Romanow Commission to investigate the role of "national values" in the shaping (or re-shaping) of health insurance programs in Canada, and more generally in the world of developed democracies. Section II is first a methodological commentary on what is and can sensibly be meant by appeals to "national values." It then addresses the general theoretical concerns about how such values might be embodied in the institutions of different Western democracies. Section III begins by taking note of the large number of reports that have recently called for reform of the Canadian health care system. After commenting briefly on the relevance of the value presumptions of these reports for this inquiry, we approach our central topic in Section IV. That part of the paper provides some comparative evidence that shows how loose the connections really are between anything coherently termed "national values" and the concrete forms of social institutions. Many variables besides "values" are at work in shaping and re-shaping particular institutions of social policy, we argue. And, conversely, we claim, many quite differently shaped social institutions may reasonably be said to embody the same set of values. In Section V, w e return to the Canadian discussion of Medicare, and argue that a range of possible amendments would be perfectly consistent with -- and therefore would be not greatly threaten -- Canadian social values. Choosing among those options requires a degree of prudence -- an attention to the political realities of conflicting interests, and to the practical realities of resource management and information -- at least as important as the values that prudence aims to advance. That a social welfare institution expresses the right values is a necessary, but is not a sufficient, basis for its adoption as a wise course of action. Section VI concludes. II. WHAT ARE "NATIONAL VALUES"? THE PRESUMPTIONS OF THE INQUIRY After all, values are held by persons, not by corporate entities that have neither minds nor desires. It is true that we may speak loosely of the "values of the common law," or the "values of the Catholic church." By such usage we mean to locate fundamental doctrines that emerge from the writings, or from the beliefs of the elite, within a certain tradition. But in general, "values" refers to subjective views of individuals about what is worthy or important. In politics, these are views about the ends that social institutions ought to advance, and the virtues they ought to embody. One's values are general; they do not dictate preferences for particular institutional structures at any level of detail (Rawls 1971). That one values privacy in health care need not lead one, for example, to endorse a particular set of detailed privacy rules (those contained in the new United States Health Insurance Portability and Accountability Act of 1996 [HIPAA] regulations, say). It leads one only to prefer institutional arrangements that protect privacy over those that do not, and arrangements that protect privacy more over those that protect it less. …
Some people with dementia are transformed by the disease, to the point that family members may de... more Some people with dementia are transformed by the disease, to the point that family members may describe them as a "different person." These transformations may be negative or positive. What factors affect the judgements of ordinary people about whether an advance directive (AD) should be followed in such cases? We conducted three studies to test the influence of (1) positive versus negative transformation and (2) "treat" versus "withhold treatment" AD on the judgements of US participants (n = 1676) as to whether the AD should be followed and the extent to which the late-stage dementia patient had become a different person. We found that participants generally endorsed following the AD, irrespective of condition, but much less so when the patient had a positive transformation. Participants also favored "treat" over "withhold treatment" ADs. Unexpectedly, we found that AD type affected "different person" judgments: participants registered significantly weaker agreement with the proposition that the patient had become a different person when the AD instructed treatment. We discuss these results in the context of Walsh's (2020) newly proposed normative model for AD decision-making.
There are at present two conflicting images of Canada's Medicare available to observant adult... more There are at present two conflicting images of Canada's Medicare available to observant adults in the United States. One is the conventional media portrait of crisis--from both U.S. and Canadian sources--an image of a program in deep trouble, overcome by problems of access, cost, and quality. The other image is far more favorable: Canadian Medicare as an structurally sound program of universal health insurance that largely satisfies those who use it, but, like all programs, requires managerial adjustment and attention to the fearfulness of Medicare's future that has marked the last decade. This was the conclusion of the report of the Canadian Institute for Health Information (CIHI) in 2000. Both portraits cannot be accurate, just as being green and white all over is logically impossible. What is the American interpreter to make of this dispute? I. THE EMERGENCY ROOM STORY: A Similar Tale with Two Meanings One place to begin is the crowded state of the North American emergency room (ER), a familiar story in both Canada and the United States over the past decade. When the winter's flu season of 2000 aggravated overcrowding in North American ERs, the U.S. (and Canadian) media took special notice. That winter The Washington Post, The New York Times, and ABC News did stories on the quality of emergency rooms in Canada. (This paralleled Canadian media treatment and in fact amplified those stories). During the same period, USA Today and Time published substantial reports on U.S. emergency rooms. But there was a distinct difference in the stories told. The three reports on Canada used the overcrowding problem to suggest Medicare is critically flawed. The two extended reports on American overcrowding did not, by contrast, indict America's overall health insurance arrangements. The similarity of the North American stories was, however, quite striking. USA Today reported that "for nearly 10 days in December of 1999, "60 of 81 [Los Angeles] hospitals were so full that hospital administrators asked to send ambulances elsewhere." The same newspaper cited a California woman who died in an ambulance awaiting hospital admission. The journalistic portrait of Canadian ERs cited similar experiences. In Toronto, overcrowding was so serious that the New York Times reported "23 of the city's hospitals [had] to turn away ambulances." ABC News cited an asthma patient who died in an ambulance that had been diverted from the nearest hospital. The important point is not the parallel reports but the different interpretations placed on them. The stories about U.S. conditions attributed the problem in part to the flu, while the reports about Canadian ERs either ignored the flu or dismissed it as an attempt by Canadian public officials to put a happy face on a Medicare in crisis. Steven Pearlstein of The Washington Post asserted that "most experts" agree that Canada's Medicare is doomed, that "while money might alleviate the shortage of advanced machinery, hospital beds, and medical school slots, it will only be a matter of time before the demand for medical services once again overtakes the willingness of voters to pay for it." (Reader's alert: most experts actually know that the demand for medical care is practically limitless and distinguish demand from serious needs. The claim of critical shortages appears universally in systems of "single-pipe financing" of health insurance. This phenomenon, called 'orchestrated outrage', is a familiar bargaining ploy which may, or may not, indicate worrisome medical circumstances. To conclude circumstances are dire requires evidence other than claims of shortage, as every national health insurance official in the Western world knows.) What the U.S. media portrayed as programmatic failure was both a reflection and an amplification of the Canadian emergency room stories. Indeed most Canadian papers got at least a month's solid copy out of hospital overcrowding, the turning away of patients from emergency rooms, and the deaths of individual patients unable to get emergency treatment. …
1. Am J Bioeth. 2006 May-Jun;6(3):56-8; discussion W51-3. Some limits of decision-theory in bioet... more 1. Am J Bioeth. 2006 May-Jun;6(3):56-8; discussion W51-3. Some limits of decision-theory in bioethics: rights, ends, and thick concepts. Latham SR. School of Law, Quinnipiac University. Comment on: Am J Bioeth. 2006 May-Jun;6(3):46-52. ...
This article offers some general criticisms of the idea that any political theory can legitimate ... more This article offers some general criticisms of the idea that any political theory can legitimate public health interventions, and then some particular criticisms of Civic Republicanism as a political theory for public health. Civic Republicanism, I argue, legitimizes liberty-infringing public health interventions by demanding high levels of civic engagement in framing and reviewing them; to demand such engagement in pursuit of such a baseline value as health will leave insufficient civic energy for the pursuit of higher values.
Reading a book is also kind of better solution when you have no enough money or time to get your ... more Reading a book is also kind of better solution when you have no enough money or time to get your own adventure. This is one of the reasons we show the conflicts of interest and the future of medicine the united states france and japan as your friend in spending the time. For more representative collections, this book not only offers it's strategically book resource. It can be a good friend, really good friend with much knowledge.
The coronavirus disease-2019 (COVID-19) has caused shortages of life-sustaining medical resources... more The coronavirus disease-2019 (COVID-19) has caused shortages of life-sustaining medical resources, and future waves of the virus may cause further scarcity. The Yale New Haven Health System developed a triage protocol to allocate scarce medical resources during the COVID-19 pandemic, with the primary goal of saving the most lives possible, and a secondary goal of making triage assessments and decisions consistent, transparent, and fair. We outline the process of developing the triage protocol, summarize the protocol itself, and discuss the major ethical challenges encountered, along with our answers to these challenges. These challenges include (1) the role of age and chronic comorbidities; (2) evaluating children and pregnant patients; (3) racial, ethnic, and socioeconomic disparities in health; (4) prioritization of healthcare workers; and (5) balancing clinical judgment versus protocolized assessments. We conclude with a review of the limitations of our protocol and the lessons learned. We hope that a robust public discussion of such protocols and the ethical challenges that they raise will result in the fairest possible processes, less need for triage, and more lives saved during future waves of the COVID-19 pandemic and similar public health emergencies.
Crisis standards of care have been widely developed by healthcare systems and states in the Unite... more Crisis standards of care have been widely developed by healthcare systems and states in the United States during the COVID-19 pandemic, and in some rare cases have actually been used to allocate medical resources. All publicly available U.S. crisis standards of care with a mechanism for allocating scarce resources make use of the Sequential Organ Failure Assessment (SOFA) score in hopes of assigning scarce resources to those patients who are more likely to survive. We reflect on the growing body of evidence suggesting that the SOFA score has limited accuracy in predicting mortality among patients hospitalized with COVID-19 and that the SOFA score systematically disfavors Black patients. Use of the SOFA score for allocating scarce resources may therefore result in Black patients with equal likelihood of survival being deprived of life-saving medical resources. There is also a risk of injustice for patients with non-COVID-19 diagnoses, for whom the SOFA score may be a more accurate prognostic score, but who might nevertheless be unfairly (de)prioritized when assessed alongside COVID-19 patients using the same scoring system. For these reasons we recommend that the SOFA score not be used for triage purposes during the COVID pandemic, and that a national effort be made to develop and empirically test crisis standards of care in advance of the next public health emergency.
We welcome and applaud Wilkinson’s (2021) impressive and subtle exploration of the possible (legi... more We welcome and applaud Wilkinson’s (2021) impressive and subtle exploration of the possible (legitimate and illegitimate) considerations of frailty as a criterion for triage in times of pandemic-driven scarcity of Intensive Care Unit (ICU) resources. To his analysis we wish to add some consideration of the consequences, for triage decisions, of the fact that frailty is sometimes reversible; some consideration of the need for additional research into the younger frail; and along the way, some views about legitimate criteria for rationing at all. Let us begin with praise. As a preliminary matter, Wilkinson has helpfully pointed out the importance of considering frailty in shared decision making, and its arguable irrelevance to always-difficult arguments about medical futility. Empirically, he has shown its relevance to calculations about survival-to-discharge, its relevance to calculations about probable longevity, its relevance to controversial arguments about quality of life, its separability from age-based rationing, and its lack of proven correlation with considerations of length of ICU stay. Procedurally, he has argued for three features of any scheme that might permissibly include consideration of frailty in determining priority of access to limited ICU resources: that the consideration of frailty be explicit; that its use be consistent across patients; and that considerations of frailty also be consistent, within any triage framework, with other considerations of other medical conditions that support similar reasons for affecting priority of access to limited ICU resources (“triage equivalence”). We applaud and welcome this contribution. Wilkinson’s substantive arguments about the use of frailty in rationing are also quite illuminating and helpful. He notes, for example, that many of the superficial criteria for frailty could misleadingly be applied to people with chronic mobility disorders and other stable chronic disabilities. He points out, also, that when frailty is introduced into triage discussions as a proxy for quality-of-life, the danger of “ableism” or disability discrimination is more difficult to avoid. Quality of life is highly subjective in nature and efforts to standardize medical judgments about it (such as QALY) are notoriously flawed. It is wellknown, for example, that persons who become disabled accept and embrace as high-quality, lives with disability that they would have rejected when they were able-bodied. Both judgments about quality of life, and judgements about tradeoffs between quality and quantity of life, are notoriously difficult to measure. Thus far we agree with Wilkinson. Where we begin to want to modify his arguments, though, is where he discusses the relationship of frailty to agediscrimination. It is certainly true that using frailty as a proxy for life-expectancy partakes less in age-discrimination than does using straight-up age. Our objection is first, to the consideration of lifeexpectancy (conceived as life-years saved) in rationing at all; and second, to the pessimistic use of a potentially-reversible condition to deny lifesaving care.
Guidelines for national human immunodeficiency virus case surveillance, including monitoring for ... more Guidelines for national human immunodeficiency virus case surveillance, including monitoring for human immunodeficiency virus infection and acquired immunodeficiency syndrome. MMWR Recommendations and Reports 48(RR13): 1-28. Molldrem, S., and A. K J Smith. 2020. Reassessing the ethics of molecular HIV surveillance in the era of cluster detection and response: Toward HIV data justice. The
Some people with dementia are transformed by the disease, to the point that family members may de... more Some people with dementia are transformed by the disease, to the point that family members may describe them as a “different person.” These transformations may be negative or positive. What factors affect the judgements of ordinary people about whether an advance directive (AD) should be followed in such cases? We conducted three studies to test the influence of (1) positive versus negative transformation and (2) “treat” versus “withhold treatment” AD on the judgements of US participants (n = 1676) as to whether the AD should be followed and the extent to which the late-stage dementia patient had become a different person. We found that participants generally endorsed following the AD, irrespective of condition, but much less so when the patient had a positive transformation. Participants also favored “treat” over “withhold treatment” ADs. Unexpectedly, we found that AD type affected “different person” judgments: participants registered significantly weaker agreement with the proposition that the patient had become a different person when the AD instructed treatment. We discuss these results in the context of Walsh’s (2020) newly proposed normative model for AD decision-making.
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Papers by Stephen Latham