Leonard Fleck

Michigan State University | MSU · Center for Ethics and Humanities in the Life Sciences

Can religious arguments provide a reasonable, justified basis for restrictive (coercive) public policies regarding numerous ethically and politically controversial medical interventions, such as research with human embryos, pre-implantation genetic diagnosis, or using artificial wombs? With Rawls, we answer negatively. Liberally reasonable policies...

In this paper, I argue for the following points. First, all of us have a presumptive moral obligation to be organ donors if we are in the relevant medical circumstances at the time of death. Second, family members should not have the right to interfere with the fulfillment of that obligation. Third, the ethical basis for that obligation is reciproc...

In the following interview, philosophers Leonard Fleck and Arthur Ward discuss the latter's recent experience of being a nondirected kidney donor. The interview took place in the Center for Bioethics and Social Justice at Michigan State University.

Solidarity is a fundamental social value in many European countries, though its precise practical and theoretical meaning is disputed. In a health care context, I agree with European writers who take solidarity normatively to mean roughly equal access to effective health care for all. That is, solidarity includes a sense of justice. Given that, I w...

Many see “precision medicine” and “precision health” complementing one another. Precision medicine is critical when we have a life-threatening cancer that could be managed with a targeted cancer therapy. Still, we would rationally prefer whatever medicine might offer that would either prevent the emergence of that cancer or treat it in its earliest...

Accelerated approval of aducanumab for mild Alzheimer's by the U.S. Food and Drug Administration on June 7, 2021, has generated substantial medical, scientific, and ethical controversy. That approval was contrary to the nearly unanimous judgment of the FDA's Advisory Committee that little reliable evidence existed of significant benefit, even thoug...

It is a serious understatement to say that this is a thought-provoking volume. The author identifies and analyses numerous ethical and policy issues regarding the ways in which we in the United States effectively establish invisible prices for saving and prolonging lives at the same time that we assert publicly the pricelessness of human life. An a...

In the view of many, heritable human genome editing (HHGE) harbors the remedial potential of ridding the world of deadly genetic diseases. A Hippocratic obligation, if there ever was one, HHGE is widely viewed as a life-sustaining proposition. The national go/no-go decision regarding the implementation of HHGE, however, must not, in the collective...

Commentary: Medical Ethics: A Distinctive Species of Ethics - Volume 29 Issue 3 - LEONARD M. FLECK

This personal narrative tugs at the heart strings. However, personal narratives are not sufficient to justify public funding for any screening policy. We have to take seriously the ‘just caring’ problem. We have only limited resources to meet virtually unlimited health care needs. No doubt, screening tests often save lives. The author wants public...

Warwick Heale has recently defended the notion of individualized and personalized Quality-Adjusted Life Years (QALYs) in connection with health care resource allocation decisions. Ordinarily, QALYs are used to make allocation decisions at the population level. If a health care intervention costs £100,000 and generally yields only two years of survi...

CHAT has its limits. It is a three-hour exercise. However, the real world problems of healthcare rationing and priority-setting are too complex for a three-hour exercise. What is needed, as a supplement, are sustained processes of rational democratic deliberation that can address the challenges to healthcare justice posed by costly emerging medical...

Meeting healthcare needs is a matter of social justice. Healthcare needs are virtually limitless; however, resources, such as money, for meeting those needs, are limited. How then should we (just and caring citizens and policymakers in such a society) decide which needs must be met as a matter of justice with those limited resources? One reasonable...

Because the demand for intensive care unit (ICU) beds exceeds the supply in general, and because of the formidable costs of that level of care, clinicians face ethical issues when rationing this kind of care not only at the point of admission to the ICU, but also after the fact. Under what conditions—if any—may patients be denied admission to the I...

I have never doubted that the problem of inequalities in health status and access to needed care is a difficult ethical and political challenge. After reading the essays in Understanding Health Inequalities and Justice: New Conversations across the Disciplines, edited by Mara Buchbinder, Michele Rivkin‐Fish, and Rebecca Walker, I concluded that des...

« Just caring » ou les « soins justes » : avons-nous besoin de fondements philosophiques ? Le problème des soins justes pose la question suivante : que signifie être une société « juste » de « prise en charge » lorsque nous avons des ressources limitées (l’argent) pour répondre aux besoins de santé, virtuellement illimités en raison de l’émergence...

Clinicians must inevitably make therapeutic decisions under nonideal conditions. They practice in circumstances that involve incomplete evidence. They deliver care in health care systems that are complex and poorly coordinated. Each of the patients that they take care of is unique while research offers evidence regarding relatively homogeneous popu...

The American College of Physicians in its ethics manual endorsed the idea that physicians ought to improve their ability to provide care to their patients more parsimoniously. This elicited a critical backlash; critics essentially claimed that what was being endorsed was a renamed form of rationing. In a recent article, Tilburt and Cassel argued th...

Let us start with a scene that I ask the reader to imagine. I am fishing in a boat with a 90-year-old acquaintance. He stands up in the boat, is a bit unsteady, and falls into the water. He used to be a very good swimmer, but he is afflicted with arthritis, which makes it impossible to swim to save his life. I have a lifesaver at hand. Am I morally...

I agree with Professor ter Meulen that there is no need to make a forced choice between "justice" and "solidarity" when it comes to determining what should count as fair access to needed health care. But he also asserts that solidarity is more fundamental than justice. That claim needs critical assessment. Ter Meulen recognizes that the concept of...

The need for health care rationing is inescapable because we have only limited resources (money) to meet virtually unlimited health care needs (generated by expanding medical technologies). Rationing means that some individuals will be denied marginally beneficial health care that costs more than a society judges fair or reasonable. The major moral...

Personalized medicine has been touted as a revolutionary form of cancer care. It has been portrayed as precision medicine, targeting with deadly accuracy cancer cells and sparing patients the debilitating broad-spectrum side effects of more traditional forms of cancer therapy. But personalized medicine still has its costs to patients and society, b...

Personalized medicine has been presented in public and professional contexts in excessively optimistic tones. In the area of cancer what has become clear is the extraordinary heterogeneity and resilience of tumors in the face of numerous targeted therapies. This is the problem of cancer drug resistance. I summarize this problem in the first part of...

Evidence-based medicine (EBM), by its ability to decrease irrational variations in health care, was expected to improve healthcare quality and outcomes. The utility of EBM principles evolved from individual clinical decision-making to wider foundational clinical practice guideline applications, cost containment measures, and clinical quality perfor...

In the age of genomic medicine we can often now do the genetic testing that will permit more accurate personal tailoring of medications to obtain the best therapeutic results. This is certainly a medically and morally desirable result. However, in other areas of medicine pharmacogenomics is generating consequences that are much less ethically benig...

The annual cost of healthcare in the United States reached $2.5 trillion in 2009 (about 17.6% of GDP) with projections to 2019 of about $4.5 trillion (about 20% of likely GDP).

What should be the content of a package of health care services that we would want to guarantee to all Americans? This question cannot be answered adequately apart from also addressing the issue of fair health care rationing. Consequently, as I argue in this essay, appeal to the language of "basic," "essential," "adequate," "minimally decent," or "...

What does it mean to be a "just" and "caring" society in meeting the health care needs of the terminally ill when we have only limited resources to meet virtually unlimited health care needs? That question is the focus of this essay. Put another way: relative to all the other health care needs in our society, especially the need for lifesaving or l...

Let me begin by thanking Paul Menzel for his thoughtful comments. I actually agree entirely with him. That is, I am not advocating that the FDA should have responsibility for addressing the "ragged edge" issue with regard to these expensive cancer drugs (or other comparable drugs for other conditions). In rereading my essay, I found a couple of sen...

The phrase "personalized medicine" has a built-in positive spin. Simple genetic tests can sometimes predict whether a particular individual will have a positive response to a particular drug or, alternatively, suffer costly and debilitating side effects. But little attention has been given to some challenging issues of justice raised by personalize...

The debate around age-based healthcare rationing was precipitated by two books in the late 1980s, one by Daniel Callahan and the other by Norman Daniels. These books ignited a firestorm of criticism, best captured in the claim that any form of age-based healthcare rationing was fundamentally ageist, discriminatory in a morally objectionable sense....

Engaging communities of color in the genetics public policy conversation is important for the translation of genetics research into strategies aimed at improving the health of all. Implementing model public participation and consultation processes can be informed by the Communities of Color Genetics Policy Project, which engaged individuals from Af...

Expressing political views in a professional setting can be detrimental to the patient-physician relationship. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

This article describes the variety of approaches used at Michigan State University's College of Human Medicine for teaching ethics, professionalism, and humanities to undergraduate medical students: courses in ethics and health policy; mentoring programs; selectives in history, literature, and spirituality; structured patient care experiences; and...

Adapting information from research trials to clinical practice is difficult. Decisions must be made about whether benefits in randomized clinical trials (RCTs) justify widespread application of the therapy. One important issue is how to explain treatment options to patients and their families in a manner that includes them in the decision-making pr...

It's not only necessary, but possible, if the public can be educated.

It's not only necessary, but possible, if the public can be educated.

What does it mean to be a just and caring society, or managed care plan, when we have only limited resources to meet virtually unlimited health care needs, and the need before us now is a person faced with death unless h/she has access to a very expensive medical intervention offering only a relatively small gain in life expectancy? This is the "la...

Ethical issues in the clinical contextEthical issues at a policy levelEthics of stem cell research and cloning

BACKGROUND Nuclear transplantation made its debut as a novel tool for defining the genetic basis for differentiation and probing the extent to which these mechanisms may be reversible. From these beginnings, a mature technology has emerged with applica-tions ranging from animal agriculture to clinical medicine. Thus, nuclear transplan-tation can be...

This is a book for reflective laypersons and health professionals who wish to better understand what the problem of healthcare rationing is all about. Ubel says clearly in the Introduction that it is unlikely that professional economists or philosophers are going to be very satisfied with this effort. For him it is more important “to draw peo...

The American Journal of Bioethics 1.2 (2001) 20-21 How can we meet competing healthcare needs fairly under reasonable resource constraints? That is the third question Daniels addresses in his essay, and I will use it to frame my comments. I endorse the broad framework for understanding healthcare justice that Daniels has presented. That is, his fai...

New genetic technologies continue to emerge that allow us to control the genetic endowment of future children. Increasingly the claim is made that it is morally "irresponsible" for parents to fail to use such technologies when they know their possible children are at risk for a serious genetic disorder. We believe such charges are often unwarrented...

To develop a managed care curriculum for primary care residents. This article outlines a 4-stage curriculum development process focusing on concepts of managed care organization and finance. The stages consist of: (1) identifying the curriculum development work group and framing the scope of the curriculum, (2) identifying stakeholder buy-in and ex...

Bioethicists appearing in the media have been accused of "shooting from the hip" (Rachels, 1991). The criticism is sometimes justified. We identify some reasons our interactions with the press can have bad results and suggest remedies. In particular we describe a target (fostering better public dialogue), obstacles to hitting the target (such as in...

Primary caregivers should be aware of recent progress in the genetics of Alzheimer disease (AD) and of the clinical and ethical considerations raised regarding the introduction of genetic testing for purposes of disease prediction and susceptibility (risk) analysis in asymptomatic individuals and diagnosis in patients who present clinically with de...

Apolipoprotein E(APOE=gene; apoE=protein) is the first identified genetic susceptibility factor for sporadic Alzheimer's disease (AD). The application of APOE genotyping to the prediction and diagnosis of AD has been a source of controversy for the public and for clinicians and scientists. These issues were explored by a 33 member working group in...

Health reform must include health care rationing, both for reasons of fairness and efficiency. Few politicians are willing to accept this claim, including the Clinton Administration. Brown and others have argued that enormous waste and inefficiency must be wrung out of our health care system before morally problematic cost constraining options, suc...

This essay argues that our national efforts at health reform ought to be informed by eleven key lessons from Oregon. Specifically, we must learn that the need for health care rationing is inescapable, that any rationing process must be public and visible, and that fair rationing protocols must be self-imposed through a process of rational democrati...

This paper describes a unit on the informed consent process taught to 119 first-year students at the Michigan State University College of Osteopathic Medicine in 1988-89. The unit consisted of a pretest and a posttest, a lecture, readings, small-group discussions, a model videotaped interview, and the students' videotaped interviews with one of two...

The Medical Ethics Resource Network (MERN) of Michigan has, over approximately 5 years, become a viable organization for disseminating educational information and raising the general standard of ethics discussion in a variety of institutional settings. This article reviews the history of the network's development, with special emphasis upon feature...

Over the past two years the debate has reemerged over whether or not the US ought to replace its current patchwork system for financing access to health care with some system of national health insurance.1 This debate last occurred in the mid-1970s, but it was effectively squelched by a worsening economy and escalating health care costs that made n...

KIE Fleck divides his paper on health care rationing into three parts. In the first part, he presents and critically assesses the moral problems posed by invisible rationing mechanisms. He claims that such mechanisms, by being localized, privitized, and unofficial, violate Rawls's publicity condition that is an essential part of our concept of just...

In a previous essay I criticized Engelhardt's libertarian conception of justice, which grounds the view that society's obligation to assure access to adequate health care for all is a matter of beneficence. Beneficence fails to capture the moral stringency associated with many claims for access to health care. In the present paper I argue that thes...

In a previous essay I criticized Engelhardt's libertarian conception of justice, which grounds the view that society's obligation to assure access to adequate health care for all is a matter of beneficence [1]. Beneficence fails to capture the moral stringency associated with many claims for access to health care. In the present paper I argue that...

Few in our society believe that access to health care should be determined primarily by ability to pay. We believe instead that society has an obligation to assure access to adequate health care for all. This is the view explicitly endorsed in the President's Commission Report Securing Access to Health Care. But there is an important moral ambiguit...

Are DRGs just? This is the primary question which this essay will answer. But there is a prior methodological question that also needs to be addressed: How do we go about rationally (non-arbitrarily) assessing whether DRGs are just or not? I would suggest that grand, ideal theories of justice (Rawls, Nozick) have only very limited utility for answe...