John Hardwig

There are good reasons — both medical and moral — for wanting to redistribute health care resources, and American hospitals and physicians are already involved in the practice of redistribution. However, such redistribution compromises both patient autonomy and the fiduciary relationship essential to medicine. These important values would be most completely preserved by a system in which patients themselves would be the agents of redistribution, by sharing their medical resources. Consequently, we should see whether patients would be willing to share before we resort to surreptitiously redistributing their resources or denying medical care to some who want and need it. We should change our health care payments systems to allow patients to donate their medical benefits to those in need.

Amid the controversies surrounding physician-assisted suicides, euthanasia, and long-term care for the elderly, a major component in the ethics of medicine is notably absent: the rights and welfare of the survivor's family, for whom serious illness and death can be emotionally and financially devastating. In this collection of eight provocative and timely essays, John Hardwig sets forth his views on the need to replace patient-centered bioethics with family-centered bioethics. Starting with a critique of the awkward language with which philosphers argue the ethics of personal relationships, Hardwig goes on to present a general statement on the necessity of family-centered bioethics. He reflects on proxy decisions, the effects of elder care on the family, the financial and lifestyle consequences of long-term care, and physician-assisted suicide from the perspective of the family. His penultimate essay, "Is There a Duty to Die?" carries the idea of family-centered ethics to its logical, controversial, conclusion; comments upon this essay from Daniel Callahan, Larry Churchill, Joanne Lynn, and journalist Nat Hentoff offer differing views on this highly charged subject. As advances in medicine prolong patient's lives, the welfare of those ultimately responsible for medical care-the family-must be addressed. Hardwig's courageous and illuminating essays set forth a new direction in bioethics: one that considers the welfare of everyone concerned.

In thc Foundations, Kant draws a distinction bctwccn action which is in accord with duty and action which is done from the motive of duty. This is 21 famous distinction, of course, and thcrc arc many interesting issues concerning it and its implications for ethical thcory. In this paper, I wish t0 focus on just 0nc noteworthy feature of K2mt’s usc of this distinction. Likc any distinction bctwccn logical compatiblcs, this 0nc yields four logically possible classes of action: (1) actions which are both in accord with duty and from duty; (2) actions which arc neither from duty nor in accord with duty; (3) actions which are in accord with duty but not from duty; and (4) actions which are from duty but not in accord with duty. What intcrcsts mc about these four possibilities is that, to thc best of my knowledge, Kant never considers or even mentions the last 0f these possibilities: action from duty but not in accord with duty. This is perhaps surprising in a philosopher with Kant’s intcrcst in logic and passion for thoroughness. Onc would have thought that hc would mention this logical possibility, cvcn if only in order to discount it as not really possible. Beginning with the idea that there arc cases of action from duty but not in accord with duty, I argue in this paper that Kant could not have admitted that thcrc can be actions of this kind, for their cxistcncc un-.

Most professions rest on the expertise of their members. Professionals are professionals primarily because they know more than most of us about something of importance to our society or to many members of it. Professionals are given power, respect, prestige, and above average incomes. If professionals are worthy of this status, it is largely because of their special knowledge and the way they use it. And if professionals have special rights and responsibilities, it is also primarily because of the social positions they occupy due to their presumed expertise.

We need to understand, and on a philosophical level, our consumer mentality. For ours is a consumer society. Yet (pace environmental philosophers) philosophers have had almost nothing to say. This paper is a start toward a normative philosophy of consumption. It explores a distinction which, if viable, has far-reaching implications — the distinction between ownership and what I call “possession.” This distinction marks two different senses in which a good or service can be mine. I argue that an approach to consumption oriented around possession rather than ownership would support the conclusion that there are prudential or self-interested, not only moral or environmental, limits to rational consumption. That would be a very desirable conclusion given that we often exceed these other limits of rational consumption.

A 78 year old married woman with progressive Alzheimer's disease was admitted to a local hospital with pneumonia and other medical problems. She recognized no one and had been incontinent for about a year. Despite aggressive treatment, the pneumonia failed to resolve and it seemed increasingly likely that this admission was to be for terminal care. The patient's husband (who had been taking care of her in their home) began requesting that the doctors be less aggressive in her treatment and, as the days wore on, he became more and more insistent that they scale back their aggressive care. The physicians were reluctant to do so, due to the small but real chance that the patient could survive to discharge. But her husband was her only remaining family, so he was the logical proxy decisionmaker. Multiple conferences ensued, and finally a conference with a social worker revealed that the husband had recently proposed marriage to the couple's housekeeper and she had accepted.

When Richard Lamm made the statement that old people have a duty to die, it was generally shouted down or ridiculed. The whole idea is just too preposterous to entertain. Or too threatening. In fact, a fairly common argument against legalizing physician-assisted suicide is that if it were legal, some people might somehow get the idea that they have a duty to die. These people could only be the victims of twisted moral reasoning or vicious social pressure. It goes without saying that there is no duty to die