Hastings Cent Rep
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When a patient lacks decision-making capacity, then according to standard clinical ethics practice in the United States, the health care team should seek guidance from a surrogate decision-maker, either previously selected by the patient or appointed by the courts. If there are no surrogates willing or able to exercise substituted judgment, then the team is to choose interventions that promote a patient's best interests. We argue that, even when there is input from a surrogate, patient preferences should be an additional source of guidance for decisions about patients who lack decision-making capacity. ⋯ Patients who lack decision-making capacity are well served by these efforts to solicit and use their preferences to promote best interests or to craft would-be autonomous patient images for use by surrogates. However, we go further: the moral reasons for valuing the preferences of patients without decision-making capacity are not reducible to either best-interests or (surrogate) autonomy considerations but can be grounded in the values of liberty and respect for persons. This has important consequences for treatment decisions involving these vulnerable patients.
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The U. S. Food and Drug Administration's drug advisory committees provide expert assessments of the safety and efficacy of new therapies considered for approval. ⋯ The committees convene at the request of the FDA when the risks and harms of novel products are not immediately clear, and their final decisions carry significant weight, as most therapies that receive advisory committee approval are subsequently approved by the FDA. In recent years, across a series of diverse publications, the financial conflicts of interest of each category of participants in the meetings have been investigated. Here, we summarize these findings and their ethical implications, focusing on the FDA Oncologic Drugs Advisory Committee, and we suggest ways to move toward more transparent and impartial advisory committee meetings.
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Consider any choice that affects some social policy. A decision that considers evidence will, at its heart, contain some kind of explicit or implicit "because" statement: "We are doing X because the evidence says Y." But can evidence ever truly speak for itself, in the sense of being reducible to objective utterances that are either correct or in need of correction? Before answering, consider what you'd prefer. Would you rather receive evidence that was free of any value judgments imposed by human actors, that was laden with value judgments that you agree with, or laden with value judgments that you disagree with? The central assertion of this essay is that, throughout policy analysis but especially in assessments of the costs and benefits of regulating versus encouraging new technologies (cost-benefit analysis, or CBA), the first possibility above is a mirage, and the second and third are self-contradictory. ⋯ The alternative judgments highlight the width of the spectrum of reasonable conclusions an analyst could reach merely by substituting other judgments for the ones currently embedded. Bringing hidden value judgments to light is doubly valuable. First, it allows discussion to ensue on a level playing field; instead of conclusory statements about what the evidence says, transparency permits statements taking the form of "when channeled through these value judgments, the evidence says this." Perhaps more importantly, transparency about value judgments permits participants in the discussions to offer interpretations of evidence contingent on there being different value judgments chosen at one or more points in the analysis, interpretations that may suggest that alternative course(s) of action are preferable to the one being championed.
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In the struggle over the durability of the Affordable Care Act, defenders of the ACA stand guard at many fronts. A major contribution of the ACA to nondiscrimination law, however, appears increasingly vulnerable. The ACA established significant new nondiscrimination protections for patients under section 1557 and its implementing regulations. ⋯ To evaluate these protections, we must consider not only their impacts on discriminatory behavior but also their behavioral and attitudinal impacts on patients and communities. This is because supportive or stigmatizing rules can exert an expressive effect: laws communicate information about prevailing social norms, they give some norms greater authority by virtue of the state's support, and they can shape community values. Through these expressive impacts, nondiscrimination laws may affect not only discriminatory behavior in health activities but also the attitudes, beliefs, and decisions of people who are legally protected.
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In 2012, Loyola University Chicago's Stritch School of Medicine became the first medical school in the United States to actively recruit and accept undocumented immigrants who received protections granted under the Deferred Action for Childhood Arrivals program that was established by presidential memorandum. By 2016, sixty-one medical schools were considering applications from DACA recipients for admission, and more than 110 students applied. ⋯ These students contribute both diversity and talent to our medical community; they could also have a significant impact on the care of underserved and immigrant populations. The recent decision by the Trump administration to rescind DACA therefore comes with serious pragmatic and ethical ramifications, impeding our medical community's efforts to develop a diverse and representative workforce committed to improving access to quality care for all patients.