On Being Ethical in Unethical Places: The Dilemmas of South African Clinical Psychologists

Practicing under the social and economic conditions created by apartheid, South African clinical psychologists face the task of questioning both the traditional values and the traditional social role of their profession. Dilemmas of trust, confidentiality, and professional competence highlight the limits of professional ethical codes.     

Patients or customers: ethical limits of market economy in health care

There is a move away from a market economy in health care in the United States and a move towards such a market in Germany. This article tries to make explicit what underlies the moral intuition that there is a tension between a market economy and health care. First, health care is analyzed in terms of the economic theory of the market and incompatibilities are described. The moral problem is identified as the danger of liquefying the distinction between persons and things. The basic moral intuition seems to be the classical social contract: as a functioning market is governed by the principle of commutative justice, free riders have to be kept away, which is achieved by coercion that is not provided by the market; coercion can be justified by a social contract. The special moral problems of a social contract for health care are discussed. It is argued that public coercion in order to collect contributions for essential health care is justified.     

You Can't Always Get (or Give) What You Want: Preferences and Their Limits

People who lack decision‐making capacity may be able to communicate preferences, which can and should inform surrogate decision‐making on their behalf. It is unclear whether making a further distinction about “capacity for preferences,” as Jason Wasserman and Mark Navin propose in this issue of the Hastings Center Report , would improve the process of surrogate decision‐making. Anyone who is regularly involved in surrogate decision‐making or who has worked to articulate decision‐making standards and processes can think of cases in which a patient's voice was ignored or his or her preferences and ability to communicate them overlooked. However, we can also think of cases in which it was unclear whether information provided by a patient, recently or in the past, should have been characterized as a preference relevant to a medical decision that the patient lacked the capacity to make. We should also recognize that clear preferences of a patient who lacks decision‐making capacity may conflict with the limits of another person or of a family's resources such that these preferences cannot guide a surrogate's decision. This patient will not get what he wants. A situation in which preferences are known and make sense but cannot be applied in a feasible way demonstrates the limits of the medical decision‐making framework concerning care that is not covered by medical insurance.