Allen Buchanan

This book is the most comprehensive treatment available of one of the most urgent - and yet in some respects most neglected - problems in bioethics: decision-making for incompetents. Part I develops a general theory for making treatment and care decisions for patients who are not competent to decide for themselves. It provides an in-depth analysis of competence, articulates and defends a coherent set of principles to specify suitable surrogate decisionmakers and to guide their choices, examines the value of advance directives, and investigates the role that considerations of cost ought to play in decisions concerning incompetents. Part II applies this theoretical framework to the distinctive problems of three important classes of individuals, many of whom are incompetent: minors, the elderly and psychiatric patients. The authors' approach combines a probing analysis of fundamental issues in ethical theory with a sensitive awareness of the concrete realities of health care institutions and the highly personal and individual character of difficult practical problems. Its broad scope will appeal to health professionals, moral philosophers and lawyers alike.

When advocates of insurance‐privatization consider whether private insurance‐dominated systems achieve justice at all, they tend to rely on an incomplete set of criteria for a just healthcare system. They also mistakenly assume that it is enough to show that justice is in principle achievable within a private insurance‐dominated system. This essay offers a more complete set of criteria for a just healthcare system. It then argues that the motivational assumptions needed to make insurance‐privatization at all plausible are inconsistent with the motivational assumptions needed to show that in practice a private insurance‐dominated system will achieve justice. A private insurance‐dominated system can be expected to satisfy the criteria for just healthcare only if there is extensive and effective regulation to constrain the normal competitive behavior of private insurers or if generous public funds are provided to fill the gaps in access left by the private insurance market. Yet the assumptions about the motivations and abilities of the public, regulators, and public officials needed to satisfy conditions or contradict the privatization advocate's explanations of how privatization will maximize efficiency, choice, and quality of care.

Many philosophers invoke the "wisdom of nature" in arguing for varying degrees of caution in the development and use of genetic enhancement technologies. Because they view natural selection as akin to a master engineer that creates functionally and morally optimal design, these authors tend to regard genetic intervention with suspicion. In Part II, we examine and ultimately reject the evolutionary assumptions that underlie the master engineer analogy (MEA). By highlighting the constraints on ordinary unassisted evolution, we show how intentional genetic modification can overcome many of the natural impediments to the human good. Our contention is that genetic engineering offers a solution that is more eff icient, reliable, versatile, and morally palatable than the lumbering juggernaut of Darwinian evolution. In Part III, we evaluate a recent attempt to ground precautionary enhancement heuristics in adaptive etiology. Our problem with this approach is two-fold: first, it is based on the same "strong adaptationist" interpretation of evolution that motivates the flawed MEA, and second, the etiological concept of function on which it relies provides indirect and potentially misleading information about the likely consequences of genetic intervention. We offer instead enhancement criteria based on causal relationships in ontogeny. We conclude that rather than grounding a presumption against deliberate genetic modification, the causal structure of the living world gives us good moral reason to pursue it