Rawlsian Justice and Palliative Care

Palliative care serves both as an integrated part of treatment and as a last effort to care for those we cannot cure. The extent to which palliative care should be provided and our reasons for doing so have been curiously overlooked in the debate about distributive justice in health and healthcare. We argue that one prominent approach, the Rawlsian approach developed by Norman Daniels, is unable to provide such reasons and such care. This is because of a central feature in Daniels' account, namely that care should be provided to restore people's opportunities. Daniels' view is both unable to provide pain relief to those who need it as a supplement to treatment and, without justice‐based reasons to provide palliative care to those whose opportunities cannot be restored. We conclude that this makes Daniels' framework much less attractive.     

RACIST APPEARANCE STANDARDS AND THE ENHANCEMENTS THAT LOVE THEM: NORMAN DANIELS AND SKIN‐LIGHTENING COSMETICS

Darker skin correlates with reduced opportunities and negative health outcomes. Recent discoveries related to the genes associated with skin tone, and the historical use of cosmetics to conform to racist appearance standards, suggest effective skin‐lightening products may soon become available. This article examines whether medical interventions of this sort should be permitted, subsidized, or restricted, using Norman Daniels's framework for determining what justice requires in terms of protecting health. I argue that Daniels's expansive view of the requirements of justice in meeting health needs offers some support for recognizing a societal obligation to provide this kind of ‘enhancement,’ in light of the strong connections between skin tone and health outcomes. On balance, however, Daniels's framework offers compelling reasons to reject insurance coverage for skin‐lightening medical interventions, including the likely ineffectiveness of such technologies in mitigating racial health disparities, and the danger that covering skin‐lightening enhancements would undermine public support for cooperative schemes that protect health. In fact, justice may require limiting access to these technologies because of their potential to exacerbate the negative effects of racism.     

HEALTH,VITAL GOALS,AND CENTRAL HUMAN CAPABILITIES

I argue for a conception of health as a person's ability to achieve or exercise a cluster of basic human activities. These basic activities are in turn specified through free‐standing ethical reasoning about what constitutes a minimal conception of a human life with equal human dignity in the modern world. I arrive at this conception of health by closely following and modifying Lennart Nordenfelt's theory of health which presents health as the ability to achieve vital goals. Despite its strengths I transform Nordenfelt's argument in order to overcome three significant drawbacks. Nordenfelt makes vital goals relative to each community or context and significantly reflective of personal preferences. By doing so, Nordenfelt's conception of health faces problems with both socially relative concepts of health and subjectively defined wellbeing. Moreover, Nordenfelt does not ever explicitly specify a set of vital goals. The theory of health advanced here replaces Nordenfelt's (seemingly) empty set of preferences and society‐relative vital goals with a human species‐wide conception of basic vital goals, or ‘central human capabilities and functionings’. These central human capabilities come out of the capabilities approach (CA) now familiar in political philosophy and economics, and particularly reflect the work of Martha Nussbaum. As a result, the health of an individual should be understood as the ability to achieve a basic cluster of beings and doings—or having the overarching capability, a meta‐capability, to achieve a set of central or vital inter‐related capabilities and functionings.     

Mental Health: The Search for a Definition

Various attempts to define the concept of “mental health” are examined. Value judgments permeate much mental health literature. Their use militates against obtaining an objective definition, capable of universal application. The acceptance of a definition including a value judgment implies taking an attitude toward a particular society and its social ideals.Present limits of competence only allow us to describe “mental health” conceptually. Such “untechnical” proposals are liable to be confused with “technical” (“scientific”) propositions. Multiple criteria are likely to be helpful in improving our concept of “mental health”.The intrusion of morals into the world of health is discussed as part of the contemporary intellectual dilemma of determined human behaviour versus human responsibility and the reality of moral values.It is suggested that “mental health” might consist simply of an individual''s possession of insight into his own personality, combined with an honest recognition and acceptance of his condition.     

Need for primary health care: an objective indicator.

The allocation of resources for primary health care should be based on the community''s needs and not only on the workload of general practitioners. I therefore present an objective indicator that may be used to assess the need for primary health care.     

On a naturalist theory of health: a critique

This paper examines the most influential naturalist theory of health, Christopher Boorse’s ‘biostatistical theory’ (BST). I argue that the BST is an unsuitable candidate for the rôle that Boorse has cast it to play, namely, to underpin medicine with a theoretical, value-free science of health and disease. Following the literature, I distinguish between “real” changes and “mere Cambridge changes” in terms of the difference between an individual’s intrinsic and relational properties and argue that the framework of the BST essentially implies a Cambridge-change criterion. The examination reveals that this implicit criterion commits the BST to the troubling view that an individual could go from being diseased to healthy, or vice versa, without any physiological change in that individual. Two problems follow: (1) the current framework of the BST is ill-equipped to formally embrace Cambridge changes and (2) it is theoretically dubious. The arguments advanced here are not limited to the BST; I suggest they extend to any naturalist claim to underpin medical practice with a value-free theory of health and disease defined in terms of an evolutionary view of biological fitness.     

Global Health Care Justice,Delivery Doctors and Assisted Reproduction: Taking a Note From Catholic Social Teachings

This article will examine the Catholic concept of global justice within a health care framework as it relates to women's needs for delivery doctors in the developing world and women's demands for assisted reproduction in the developed world. I will first discuss justice as a theory, situating it within Catholic social teachings. The Catholic perspective on global justice in health care demands that everyone have access to basic needs before elective treatments are offered to the wealthy. After exploring specific discrepancies in global health care justice, I will point to the need for delivery doctors in the developing world to provide basic assistance to women who hazard many pregnancies as a priority before offering assisted reproduction to women in the developed world. The wide disparities between maternal health in the developing world and elective fertility treatments in the developed world are clearly unjust within Catholic social teachings. I conclude this article by offering policy suggestions for moving closer to health care justice via doctor distribution.     

DuBois the pan-Africanist and the development of African nationalism

While W.E.B. DuBois's importance as a political activist and writer is well-documented, a ‘DuBoisian’ political theory has proved illusory. I argue that the key to change and continuity in DuBois's work is his pan-Africanism, which he used to develop a broad theory of anti-colonial nationalism. This reading of his legacy emphasizes DuBois's singular role in shaping anti-colonial discourse in the postwar era, especially in Africa, as well as in theorizing African nationalism and the African diaspora. It also allows us to understand the contradiction of the early, liberal DuBois's views on race and his later preoccupation with Communism. I suggest that across both positions, DuBois's actual political arguments remained over-determined by his positionality within the colonial world, producing a set of anti-colonial arguments that while rooted in the economic exploitation of the colonies, appeal to liberal universalizing standards of progress and modernity.     

The Problem of Generalization in the Works of L. S. Vygotsky

An aspect of Vygotsky's psychological theory which is still meaningful as a genuine scientific problem today is the treatment he gave to the structure, function, and formation of generalization as a special means of reflecting reality in human consciousness. Many of the central propositions of the theory — concerning such questions as the role of symbols in the establishment of higher mental functions, the hierarchical structure of consciousness, and the connection between instruction and development — were refined, concentrated, and cast in a new light by the concept of generalization which Lev Semyonovich worked on so intensively in the last years of his life. The problem of generalization is the knot that ties together the fundamental strands of the whole conception. By carefully untying it one can avoid misunderstandings in evaluating some of Vygotsky's propositions, and, even more important, one can then correctly understand his fundamental ideas, which he clearly formulated but was not able to develop fully. The significance of these ideas is such that they belong in the arsenal of modern psychology to resolve burning theoretical and practical problems of the day.     

The World Health Organisation. Interview with the director general. Interview by Fiona Godlee.

Dr Hiroshi Nakajima was elected director general of WHO in 1988. Born in Japan, he trained as a psychiatrist before joining WHO in 1973. He was WHO''s regional director for the Western Pacific from 1979 to 1988. His term of office has been marked by criticism of his management style and allegations of misuse of WHO''s funds. I spoke to him at WHO''s headquarters in Geneva in July. I have presented the interview in the form of questions and answers. It would be misleading, however, not to make clear that in doing so I have transcribed conversation which was at times extremely difficult to follow. I feel that it is important to emphasise this in the context of an interview with an international leader, one of whose primary tasks must be to communicate his views on health to people across the world. The interviews gave me first hand experience of the difficulties in communication that staff, diplomats, and others, including Japanese leaders, have consistently commented on since Dr Nakajima took office.     

Doctors and patients don't agree: cross sectional study of patients' and doctors' perceptions and assessments of disability in multiple sclerosis.

OBJECTIVES: To compare the judgments of clinicians on which domains of health in the short form questionnaire (SF-36) would be most important to patients with multiple sclerosis with the opinions of patients themselves; to compare assessment of physical disability in multiple sclerosis by a clinician using Kurtzke''s expanded disability status scale and a non-clinically qualified assistant using the Office of Population Census and Surveys'' (OPCS) disability scale with self assessment of disability and other domains of health related quality of life by patients using the SF-36 and the EuroQol questionnaire; and to compare the scores of patients for each domain of the SF-36 with control data matched for age and sex. DESIGN: Cross sectional study. SETTING: Clinical department of neurology, Edinburgh. SUBJECTS: 42 consecutive patients with multiple sclerosis attending a neurology outpatient clinic for review or a neurology ward for rehabilitation. MAIN OUTCOME MEASURES: Scores on the SF-36; EuroQol; Kurtzke''s expanded disability status scale; the OPCS disability scale. RESULTS: Patients and clinicians disagreed on which domains of health status were most important (chi 2 = 21, df = 7, P = 0.003). Patients'' assessment of their physical disability using the physical functioning domain of the SF-36 was highly correlated with the clinicians'' assessment (r = -0.87, P < 0.001) and the non-clinical assessment (r = -0.90, P < 0.001). However, none of the measures of physical disability correlated with overall health related quality of life measured with EuroQol, Quality of life correlated with vitality, general health, and mental health in the SF-36, each of which patients rated as more important than clinicians and for each of which patients scored lower than the controls. CONCLUSIONS: Patients with multiple sclerosis and possibly those with other chronic diseases are less concerned than their clinicians about physical disability in their illness. Clinical trials in multiple sclerosis should assess the effect of treatment on the other elements of health status that patients consider important, which are also affected by the disease process, are more closely related to overall health related quality of life, and may well be adversely affected by side effects of treatment.     

Genetic Counseling—A Health Department Service to Physicians

Questions about inheritance in all kinds of diseases and defects are commonly asked of nearly all physicians. In attempting to answer these questions, however, the physician is often hampered by lack of formal instruction in clinical genetics.Since the health department, if it is to carry out its epidemiologic function, must be as concerned over the increasing identification of genetic agents in disease as it is and has been over environmental disease agents, it should come to represent a source of assistance not now generally available to the physician. In short, as it carries out those activities by which its store of general genetic information is increased, and until other sources of genetic consultation become reasonably available, the health department can be of real service to physicians as a resource to which they may turn for help when dealing with families wanting genetic information.Such a service has been provided experimentally for the last two years by the Contra Costa County Health Department.This program calls for the taking of family pedigrees by public health nurses on families with questions of a genetic nature who are health department clients and on families who are referred by their private physicians for this service. An interpretation of each pedigree is made by the department''s physician in charge of the program and submitted to the family''s physician for his use in counseling the family. Evidence to date suggests the process can be a highly useful service to the practitioner and his patient.     

JUSTICE, STIGMA, AND THE NEW EPIDEMIOLOGY OF HEALTH DISPARITIES

Recent research in epidemiology has identified a number of factors beyond access to medical care that contribute to health disparities. Among the so-called socioeconomic determinants of health are income, education, and the distribution of social capital. One factor that has been overlooked in this discussion is the effect that stigmatization can have on health. In this paper, I identify two ways that social stigma can create health disparities: directly by impacting health-care seeking behaviour and indirectly through the internalization of negative interpersonal judgments. I then argue that social arrangements that foster self-respect can reduce the impact of stigmatization on health disparities. I conclude by showing how John Rawls' conception of justice can be used to address the intersection of stigma, health, and self-respect, in contrast to critics of his position, who have seen him as excessively focused on the allocation of material goods.     

Perceived Social Support Moderates the Link between Attachment Anxiety and Health Outcomes

Two literatures have explored some of the effects intimate relationships can have on physical and mental health outcomes. Research investigating health through the lens of attachment theory has demonstrated that more anxiously attached individuals in particular consistently report poorer health. Separate research on perceived social support (e.g., partner or spousal support) suggests that higher support has salutary influences on various health outcomes. Little to no research, however, has explored the interaction of attachment anxiety and perceived social support on health outcomes. The present study examined the attachment-health link and the moderating role of perceived social support in a community sample of married couples. Results revealed that more anxious persons reported poorer overall physical and mental health, more bodily pain, more medical symptoms, and impaired daily functioning, even after controlling for age, relationship length, neuroticism, and marital quality. Additionally, perceived social support interacted with attachment anxiety to influence health; more anxious individuals'' health was poorer even when perceived social support was high, whereas less anxious individuals'' health benefited from high support. Possible mechanisms underlying these findings and the importance of considering attachment anxiety in future studies of poor health in adulthood are discussed.     

Public health in inner London.

One of Sir Bernard Tomlinson''s aims in his inquiry into London''s health services was to advise the secretary of state for health on the future balance of primary and secondary health care "taking account of the health needs of Londoners." Sir Bernard, however, also made it clear that "we have not seen it as part of our remit to carry out a comprehensive needs assessment for the whole of London," but concluded that the extremes of health need found in London were "unparalleled in the rest of England." Dr Jacobson highlights some of the major determinants of health inequality in inner London and assesses the extent to which the proposed solutions are likely to meet these needs.     

Menstrual cycle phase alters women's sexual preferences for composers of more complex music

Over 140 years ago Charles Darwin first argued that birdsong and human music, having no clear survival benefit, were obvious candidates for sexual selection. Whereas the first contention is now universally accepted, his theory that music is a product of sexual selection through mate choice has largely been neglected. Here, I provide the first, to my knowledge, empirical support for the sexual selection hypothesis of music evolution by showing that women have sexual preferences during peak conception times for men that are able to create more complex music. Two-alternative forced-choice experiments revealed that woman only preferred composers of more complex music as short-term sexual partners when conception risk was highest. No preferences were displayed when women chose which composer they would prefer as a long-term partner in a committed relationship, and control experiments failed to reveal an effect of conception risk on women''s preferences for visual artists. These results suggest that women may acquire genetic benefits for offspring by selecting musicians able to create more complex music as sexual partners, and provide compelling support for Darwin''s assertion ‘that musical notes and rhythm were first acquired by the male or female progenitors of mankind for the sake of charming the opposite sex’.     

Lévy-Bruhl and Modes of Thought: A Re-Appraisal

In this paper I examine the relevance of Lévy Bruhl's work for contemporary anthropological theory. Starting with a brief summary of his writings, I go on to explore his concept of primitive thought, showing how his ideas were influenced by Durkheim and depended mainly on the notion of collective representations. However, Lévy-Bruhl's use of this concept, while Durkheimian in its sources, differed from Durkheim's original usage. It is this difference which I explore following suggestions by Waismann and other logicians interested in non-standard logics. I assess the response to Lévy-Bruhl's ideas both by his contemporaries and by more recent anthropologists, pointing out that much of their criticism is based on a misunderstanding of his position, combined with a lack of awareness on the part of most anthropologists of non-standard, alternative logics. Finally I argue the importance of Lévy-Bruhl's questions (but not his answers) for anthropologists interested in exploring modes of thought found in social structures which legitimate marked ambiguities in discourse and practice, and whose formal logical models do not conform to the aristotelian naradigm.     

STANDARD CIRCUMSTANCES AND VITAL GOALS: COMMENTS ON VENKATAPURAM'S CRITIQUE

This article is a reply to Venkatapuram's critique in his article Health, Vital Goals, Capabilities, this volume. I take issue mainly with three critical points put forward by Venkatapuram with regard to my theory of health. (1) I deny that the contents of my vital goals are relative to each community or context, as Venkatapuram claims. There is no conceptual connection at all between standard circumstances and vital goals, as I understand these concepts. (2) Venkatapuram notes that I stop short of filling the framework of vital goals with any content and thereby make my concept of health less concrete. I reply that some vital goals are indeed universal, viz. the ones which are necessary conditions for survival. Many other vital goals are individual and cannot therefore be included in a universal list. (3) Venkatapuram claims that my definition of vital goals is too broad, since it entails that some persons without any disease can be regarded as ill. However, in my understanding health is a relational concept from a state of complete health to a state of maximal illness. In this framework, a minor reduction of a state of complete health does not entail illness. This article also contains a comparison between my theory of health and Martha Nussbaum's theory of capabilities for dignity.     

Anglo-Canadian Exchange in General Practice: British View of Canadian General Practice

The Canadian general practitioner is remunerated by an item-of-service system of payment which encourages servicing demands rather than needs, discourages delegation of work to paramedical workers, and involves his staff in a massive amount of paper work. He has an excellent hospital attachment, which unfortunately is overdone. His community facilities are piecemeal and his office organization is rudimentary. There are few incentives for good general practice in the community. He spends an inordinate amount of time examining well people. The university departments of general practice are extremely good and much should be heard from them very quickly. The patient''s attitude towards his doctor is quite different from the one prevailing currently in Britain.I returned happily to British general practice.     

What's in a (Big) Name? The Art and Agency of a Bornean Photographic Collection

This article concerns the photographic collection of Paka anak Otor, the Bidayuh owner of a ‘mini-museum’ in Sarawak, Malaysian Borneo, and how it became entangled in his claims to status within and beyond his village. Superficially, the situation is easily apprehended via two analogous approaches within photographic theory and Southeast Asianist ethnography, which treat objects and images as representations or bearers of power and meaning. Here I suggest that such approaches end up eliding the action-centred nature of Paka's ‘big name’-making ambitions. In response, I approach his photographic collection through an analytical framework deriving from Alfred Gell's seminal theory, Art and Agency (1998), which has hitherto remained marginal to Southeast Asianist anthropology. I argue that, more than merely symbolising or bearing his ‘big name’, Paka's photographs were agentive image-objects that actively instantiated it. I conclude by asking how such an analytical shift might encourage a reconceptualisation of ‘power’ and ‘objecthood’ in Southeast Asianist anthropology.