Faculty Bibliography

Older parenthood raises a variety of important factual and ethical questions. None of the questions have received sufficient attention despite the rapid expansion in the United States and other nations in the numbers of older parents. We do not know much about the safety, economic, and psychosocial impact of these emerging practices on children or parents. Nor have there been many analytical considerations of the ethical issues raised. We argue in this article that there are reasons for concern when older persons seek to utilize fertility treatments, including the safety of pregnancy for older women, risks posed to children delivered by older mothers, issues around what constitutes safe conditions for having a child relative to the age of parents, and the importance of guaranteeing that someone will serve in the parental role should an older parent or parents become disabled or die. To protect the best interest of children created by technology in new familial circumstances, internationally recognized and enforced standards for fertility clinics to follow ought to be enacted in making decisions about treating older parents seeking infertility services.

Clinical research has been expanding into poor nations in recent years. In doing research in such settings, the response to challenges arising due to the vulnerability and resultant potential exploitation of very poor subject populations is heightened awareness of the need for adequate local oversight and regulation. More regulation, however, often is difficult to implement and may not be practical. The provision of benefit at the conclusion of clinical trials in poor nations or for poor people is a better response to the moral challenge of exploitation.

Competing visions for health reform in the United States and renewed interest in health technology assessment (HTA) have led to fierce national debates about the appropriateness of rationing. Because of a limited supply of organs, kidney transplantation has always required rationing and overt discussion of the ethics that guide it, but the field of transplantation has also contended recently with internal calls for a new rationing system. The aim of the Life Years from Transplantation (LYFT) proposal is to allocate kidneys to patients who obtain the greatest survival benefit from transplantation, which would lengthen the lives of kidney transplant recipients but restrict the ability of older Americans to obtain a transplant. The debate around the LYFT proposal reveals the ethical and policy challenges of identifying which patients should receive a treatment based on the results of cost-effectiveness and other HTA studies. This article argues that attempts to use HTA for healthcare rationing are likely to disadvantage older patients. Guiding principles to help ensure that resources such as kidneys are justly allocated across the life span are proposed.

Much attention has been focused in recent years on the ethical acceptability of physicians receiving gifts from drug companies. Professional guidelines recognize industry gifts as a conflict of interest and establish thresholds prohibiting the exchange of large gifts while expressly allowing for the exchange of small gifts such as pens, note pads, and coffee. Considerable evidence from the social sciences suggests that gifts of negligible value can influence the behavior of the recipient in ways the recipient does not always realize. Policies and guidelines that rely on arbitrary value limits for gift-giving or receipt should be reevaluated.