Virginia Ashby, Virginia, Virginia A. Sharpe

Within health care systems, negative perceptions of lesbian, gay, bisexual, and transgender persons have often translated into denial of services, denial of visitation rights to same‐sex partners, reluctance on the part of LGBT patients to share personal information, and failure of workers to assess and recognize the unique health care needs of these patients. Other bureaucratic forms of exclusion have included documents, forms, and policies that fail to acknowledge a patient's valued relationships because of, for example, a narrow definition of “spouse,” “parent,” or “family.” Bureaucratic exclusion has taken a particularly prominent form in the U.S. military. Until its repeal and termination in 2011, the “Don't Ask, Don't Tell” policy had for eighteen years barred openly gay men and lesbians from serving in the military. Among the effects of DADT is a dearth of information about the number and needs of LGBT service members who transition to the Veterans Health Administration for health care at the end of their military service. The long‐standing social stigma against LGBT persons, the silence mandated by DADT, and the often unrecognized bias built into the fabric of bureaucratic systems make the task of creating a welcoming culture in the VHA urgent and challenging.The VHA has accepted a commitment to that task. Its Strategic Plan for fiscal years 2013 through 2018 stipulates that “[v]eterans will receive timely, high quality, personalized, safe, effective and equitable health care irrespective of geography, gender, race, age, culture or sexual orientation.” To achieve this goal, the VHA undertook a number of coordinated initiatives to create an environment and culture that is informed, welcoming, positive, and empowering for the LGBT veterans and families whom the agency serves.

In this dissertation, I question whether deontological liberalism or "justice theory" is an adequate framework for the development of medical ethical theory. I argue that the medical moral domain is inadequately described by the norms of impartiality, universality, and equality that characterize the liberal ideal. The foci of my inquiry are the libertarian theory of H. T. Engelhardt, Jr. and the contractarian theory of R. M. Veatch. The liberal ideal fails as a foundation for medical ethics in at least four ways. First, in order to remain consistent with the paradigm of liberal citizenship, justice-oriented medical ethics must construe the moral self as a generic, autonomous, rational entity. As a result of this minimal construal of personality, the participants in medical relationships are regarded as equals and no moral recognition is given to the fact that one of the participants in the medical relationship is ill. Second, insofar as justice-oriented medical ethics interprets the relationship between doctor and patient as an association of equals, it must maintain that the physician's primary moral obligation is to respect patient autonomy rather than to benefit the patient. Third, because a faithful adaptation of justice theory must remain neutral regarding goods, deontological liberal medical ethics must deny or ignore the fact that the physician-patient relationship is initiated on the basis of a human need to promote and preserve health. Fourth, if, as Engelhardt and Veatch maintain, there is nothing morally distinctive about medical relationships, then neither theorist can explain why such relationships require the specific theoretical attention that they are given in the form of deontological liberal theories of medical ethics. ;I offer the teleological theory of E. D. Pellegrino and D. C. Thomasma as an alternative model of medical ethics. On this model, medicine's moral significance is not a function of individual autonomy, but rather, it is a function of the healing relationship as a unique human activity. The emphasis on relationship and human need, rather than individual autonomy allies this theory with the "morality of care" described by Carol Gilligan

Following up on a 1989 paper on the subject, this essay revisits the question of ethical expertise in the court room. Informed by recent developments in the use of ethics experts, the authors argue 1) that the adversarial nature of court proceedings challenges the integrity of the ethicist's pedagogical role; 2) that the use of ethics experts as normative authorities remains dubious; 3) that clarification of the State's interest in “protecting the ethical integrity of the medical profession” is urgently required; and 4) that the expertise of the ethicist may be more appropriately used in advising the legislature than in influencing the court

Edmund Pellegrino has argued that the dramatic changes in American health care call for critical reflection on the traditional norms governing the therapeutic relationship. This paper offers such reflection on the obligation to do no harm. Drawing on work by Beauchamp and Childress and Pellegrino and Thomasma, I argue that the libertarian model of medical ethics offered by Engelhardt cannot adequately sustain an obligation to do no harm. Because the obligation to do no harm is not based simply on a negative duty of nonmaleficence but also on a positive duty of beneficence, I argue that it is best understood to derive from the fiduciary nature of the healing relationship.

Carol Gilligan has identified two orientations to moral understanding; the dominant justice orientation and the under-valued care orientation. Based on her discernment of a voice of care, Gilligan challenges the adequacy of a deontological liberal framework for moral development and moral theory. This paper examines how the orientations of justice and care are played out in medical ethical theory. Specifically, I question whether the medical moral domain is adequately described by the norms of impartiality, universality, and equality that characterize the liberal ideal. My analysis of justice -oriented medical ethics, focuses on the libertarian theory of H.T. Engelhardt and the contractarian theory of R.M. Veatch. I suggest that in the work of E.D. Pellegrino and D.C. Thomasma we find not only a more authentic representation of medical morality but also a project that is compatible with the care orientation's emphasis on human need and responsiveness to particular others