The realities and myths of long-term care and the challenges it poses for the ethics of autonomy are analyzed in this perceptive work. The book defends the concept of autonomy, but argues that the standard view of autonomy as non-interference and independence has only a limited applicability for long term care. The treatment of actual autonomy stresses the developmental and social nature of human persons and the priority of identification over autonomous choice. The work balances analysis of the ethical concepts (...) associated with autonomy with discussion of the implications of the ethical analysis for long term care. A central chapter involves a phenomenological analysis of four general features of everyday experience (space, time, communication, and affectivity) and explores their practical implications for long term care. This work concludes with a discussion of the advantages associated with a phenomenologically-inspired treatment of actual autonomy for the ethics of long-term care. (shrink)

This paper offers an exposition of what the question of method in ethics consultation involves under two conditions: when ethics consultation is regarded as a practice and when the question of method is treated systematically. It discusses the concept of the practice and the importance of rules in constituting the actions, cognition, and perceptions of practitioners. The main body of the paper focuses on three elements of the question of method: canon, discipline, and history, which are treated heuristically to outline (...) what the question of method in ethics consultation fully involves. (shrink)

Respecting the autonomy of disabled people is an important ethical issue for providers of long-term care. In this influential book, George Agich abandons comfortable abstractions to reveal the concrete threats to personal autonomy in this setting, where ethical conflict, dilemma and tragedy are inescapable. He argues that liberal accounts of autonomy and individual rights are insufficient, and offers an account of autonomy that matches the realities of long-term care. The book therefore offers a framework for carers to develop an ethic (...) of long-term care within the complex environment in which many dependent and aged people find themselves. Previously published as Autonomy and Long-term Care, this revised edition, in paperback for the first time, takes account of recent work and develops the author's views of what autonomy means in the real world. It will have wide appeal among bioethicists and health care professionals. (shrink)

How closely involved with hospital ethics committees should patients and their families become? Should they routinely have access to committees, or be empowered to initiate consultations? To what extent should they be informed of the content or outcome of committee deliberations? Seeing ethics committees as the locus of competing responsibilities allows us to respond to the questions posed by a patient rights model and to acknowledge more fully the complex moral dynamics of clinical medicine.

The realities of long‐term care call for a refurbished, concrete concept of autonomy that systematically attends to the history and development of persons and takes account of the experiences of daily living.

Authority is an uneasy, political notion. Heard with modern ears, it calls forth images of oppression and power. In institutional settings, authority is everywhere present, and its use poses problems for the exercise both of individual autonomy and of responsibility. In medical ethics, the exercise of authority has been located on the side of the physician or the health care institution, and it has usually been opposed by appeal to patient autonomy and rights. So, it is not surprising, though still (...) ironic, that ethics consultation, which develops from this patient rights-dominated ethic, should itself bring forth questions of authority. Nonetheless, it does.Insofar as authority has been discussed in ethics consultations, it has been understandably approached from the broad perspective of legitimation and power, which are common themes in social and political treatments of authority. These treatments have dominated twentieth-century discussions of authority, which primarily view authority as legitimate power. (shrink)

Authority is an uneasy, political notion. Heard with modern ears, it calls forth images of oppression and power. In institutional settings, authority is everywhere present, and its use poses problems for the exercise both of individual autonomy and of responsibility. In medical ethics, the exercise of authority has been located on the side of the physician or the health care institution, and it has usually been opposed by appeal to patient autonomy and rights. So, it is not surprising, though still (...) ironic, that ethics consultation, which develops from this patient rights-dominated ethic, should itself bring forth questions of authority. Nonetheless, it does. Insofar as authority has been discussed in ethics consultations, it has been understandably approached from the broad perspective of legitimation and power, which are common themes in social and political treatments of authority. These treatments have dominated twentieth-century discussions of authority, which primarily view authority as legitimate power. (shrink)

Recent philosophical attention to the language of disease has focused primarily on the question of its value-neutrality or non-neutrality. Proponents of the value-neutrality thesis symbolically combine political and other criticisms of medicine in an attack on what they see as value-infected uses of disease language. The present essay argues against two theses associated with this view: a methodological thesis which tends to divorce the analysis of disease language from the context of the practice of medicine and a substantive thesis which (...) holds that disease language is evaluatively neutral. In particular, the essay critically focuses on the value neutral position adopted by Christopher Boorse, which he terms a functional theory of disease. The argument concerns whether or not one can have value neutral description of disease states or whether disease language essentially involves values. (shrink)

RECENT PHILOSOPHICAL ATTENTION TO THE LANGUAGE OF DISEASE HAS FOCUSED PRIMARILY ON THE QUESTION OF ITS VALUE-NEUTRALITY OR NON-NEUTRALITY. PROPONENTS OF THE VALUE-NEUTRALITY THESIS SYMBOLICALLY COMBINE POLITICAL AND OTHER CRITICISMS OF MEDICINE IN AN ATTACK ON WHAT THEY SEE AS VALUE-INFECTED USES OF DISEASE LANGUAGE. THE PRESENT ESSAY ARGUES AGAINST TWO THESES ASSOCIATED WITH THIS VIEW: A METHODOLOGICAL THESIS WHICH TENDS TO DIVORCE THE ANALYSIS OF DISEASE LANGUAGE FROM THE CONTEXT OF THE PRACTICE OF MEDICINE AND A SUBSTANTIVE THESIS WHICH (...) HOLDS THAT DISEASE LANGUAGE IS EVALUATIVELY NEUTRAL. IN PARTICULAR, THE ESSAY CRITICALLY FOCUSES ON THE VALUE NEUTRAL POSITION ADOPTED BY CHRISTOPHER BOORSE, WHICH HE TERMS A FUNCTIONAL THEORY OF DISEASE. THE ARGUMENT CONCERNS WHETHER OR NOT ONE CAN HAVE VALUE NEUTRAL DESCRIPTION OF DISEASE STATES OR WHETHER DISEASE LANGUAGE ESSENTIALLY INVOLVES VALUES. (shrink)

In a practice like ethics consultation, quality and accountability are intertwined. Critics of ethics consultation have complained that clinical ethics consultants exercise power or influence in patient care without sufficient external oversight. Without oversight or external accountability, ethics consultation is seen as more sophistical than philosophical. Although there has been more discussion of accountability, concern for quality in ethics consultation is arguably more important, because it represents a central challenge for the field, namely, how to structure a responsible practice of (...) ethics consultation. (shrink)

This paper discusses the importance of Richard M. Zaners work on clinical ethics for answering the question: what kind of doing is ethics consultation? The paper argues first, that four common approaches to clinical ethics – applied ethics, casuistry, principlism, and conflict resolution – cannot adequately address the nature of the activity that makes up clinical ethics; second, that understanding the practical character of clinical ethics is critically important for the field; and third, that the practice of clinical ethics is (...) bound up with the normative commitments of medicine as a therapeutic enterprise. (shrink)

In “Deception and the Clinical Ethicist,” Christopher Meyers defends that view that deception practiced by clinical ethicists is legitimate if it satisfies a series of justifying conditions (Meyers...

Clinical ethics consultation has developed from local pioneer projects into a field of growing interest among both clinicians and ethicists. What is needed are more systematic studies on the ethical challenges faced in clinical practice and problem solving through ethics consultation from interdisciplinary perspectives. The Thematic Issue covers a range of topics and includes five recent studies from various European countries and the USA, focusing on issues such as the ethical difficulties of end of life decisions, experiences with newly developed (...) or well established ethics consultation services, and the expectations of physicians in various clinical fields who are still unfamiliar with clinical ethics consultation. The papers included illustrate the interface between different socio-cultural contexts and their ways of dealing with clinical ethics consultation. They deepen the dialogue on clinical ethics consultation that has emerged at the European and International level. (shrink)

The philosophy of medicine and psychiatry has considered the defining of disease, illness, and disorder an important project for over three decades. Within this literature, accounts based on adaptive "functions" have been prominent, particularly in the DSM nosology. In response to this trend, Jerome Wakefield has presented a view of mental disorder as "harmful dysfunction." In this view, "harm" contributes the value-element to disorder concepts, while "dysfunction" implies a value-free foundation as long as the latter is grounded in evolutionary biology. (...) In a critical review of Wakefield's and others' functionalist arguments for disorder concepts, we make four major points. We recommend a shift away from the definition of value-free disorder concepts, instead emphasizing the analysis of the logical features and the value commitments in nosological categories. (shrink)

While there is no denying the relevance of ethical knowledge and analytical and cognitive skills in ethics consultation, such knowledge and skills can be overemphasized. They can be effectively put into practice only by an ethics consultant, who has a broad range of other skills, including interpretive and communicative capacities as well as the capacity effectively to address the psychosocial needs of patients, family members, and healthcare professionals in the context of an ethics consultation case. In this paper, I discuss (...) how emotion can play an important interpretive role in clinical ethics consultation and why attention to the role of defense mechanisms can be helpful. I concentrate on defense mechanisms, arguing first, that the presence of these mechanisms is understandable given the emotional stresses and communicative occlusions that occur between the families of patients and critical care professionals in the circumstances of critical care; second, that identifying these mechanisms is essential for interpreting and managing how these factors influence the way that the “facts” of the case are understood by family members; and, third, that effectively addressing these mechanisms is an important component for effectively doing ethics consultation. Recognizing defense mechanisms, understanding how and why they operate, and knowing how to deal with these defense mechanisms when they pose problems for communication or decision making are thus essential prerequisites for effective ethics consultation, especially in critical care. (shrink)

This paper discusses the importance of Richard M. Zaner’s work on clinical ethics for answering the question: what kind of doing is ethics consultation? The paper argues first, that four common approaches to clinical ethics – applied ethics, casuistry, principlism, and conflict resolution – cannot adequately address the nature of the activity that makes up clinical ethics; second, that understanding the practical character of clinical ethics is critically important for the field; and third, that the practice of clinical ethics is (...) bound up with the normative commitments of medicine as a therapeutic enterprise. (shrink)

Free and informed consent is generally acknowledged as the legal andethical basis for living organ donation, but assessments of livingdonors are not always an easy matter. Sometimes it is necessary toinvolve psychosomatics or ethics consultation to evaluate a prospectivedonor to make certain that the requirements for a voluntary andautonomous decision are met. The paper focuses on the conceptualquestions underlying this evaluation process. In order to illustrate howdifferent views of autonomy influence the decision if a donor's offer isethically acceptable, three cases (...) are presented – from Germany, theUnited States, and India. Each case features a person with questionabledecision-making capacity who offered to donate a kidney for a siblingwith severe renal insufficiency. Although the normative framework issimilar in the three countries, different or sometimes even contraryarguments for and against accepting the offer were brought forward. Thesubsequent analysis offers two explanations for the differences inargumentation and outcome in spite of the shared reference to autonomyas the guiding principle: (1) Decisions on the acceptability of a livingdonor cannot simply be deducted from the principle of autonomy but needto integrate contextual information; (2) understandings of the wayautonomy should be contextualized have an important influence on theevaluation of individual cases. Conclusion: Analyzing the conceptualassumptions about autonomy and its relationship to contextual factorscan help in working towards more transparent and better justifieddecisions in the assessment of living organ donors. (shrink)

The proliferation of ethics committees and ethics consultation services has engendered a discussion of the issue of the expertise of those who provide clinical ethics consultation services. In this paper, I discuss two aspects of this issue: the cognitive dimension or content knowledge that the clinical ethics consultant should possess and the practical dimension or set of dispositions, skills, and traits that are necessary for effective ethics consultation. I argue that the failure to differentiate and fully explicate these dimensions contributes (...) to the confusion over the issue of expertise and fuels, at least partly, the controversies about expertise (or authority) in ethics and the legitimacy of the use of ethical knowledge in clinical ethics consultation. (shrink)

The aim of this study was to assess nurses’ and physicians’ ethical dilemmas in clinical practice. Nurses and physicians of the Clinical Hospital Centre Rijeka were surveyed (N = 364). A questionnaire was used to identify recent ethical dilemma, primary ethical issue in the situation, satisfaction with the resolution, perceived usefulness of help, and usage of clinical ethics consultations in practice. Recent ethical dilemmas include professional conduct for nurses (8%), and near-the-end-of-life decisions for physicians (27%). The main ethical issue is (...) limiting life-sustaining therapy (nurses 15%, physicians 24%) and euthanasia and physician-assisted suicide (nurses 16%, physicians 9%). The types of help available are similar for nurses and physicians: obtaining complete information about the patient (37% vs. 50%) and clarifying ethical issues (31% vs. 39%). Nurses and physicians experience similar ethical dilemmas in clinical practice. The usage of clinical ethics consultations is low. It is recommended that the individual and team consultations should be introduced in Croatian clinical ethics consultations services. (shrink)

Volume 19, Issue 6, June 2019, Page 1-3.

This article accepts the proposition that old people want to be treated with dignity and that statements about dignity point to ethical duties that, if not independent of rights, at least enhance rights in ethically important ways. In contexts of policy and law, dignity can certainly have a substantive as well as rhetorical function. However, the article questions whether the concept of dignity can provide practical guidance for choosing among alternative approaches to the care of old people. The article explores (...) the paradoxical relationship between the apparent lack of specific content in many conceptions of dignity and the broad utility that dignity appears to have as a concept expressive of shared social understandings about the status of old people. (shrink)

In this paper I analyze the alleged conflict between economic incentives to efficiently utilize health care resources and the obligation to provide patients with the best possible medical care. My analysis is developed in four stages. First, I discuss briefly the nature of prospective payment systems and economic incentives as well as the issue of professional autonomy. Second, I disscuss the notion of an incentive for action both as an economic incentive and as a concept of moral psychology. Third, I (...) analyze several definitions of the physician's professional obligation and discuss four conditions that morally qualify the obligation. And fourth, I explore why the views of economists and physicians differ so strikingly on the question of economic incentives. In the process of this analysis, I argue that criticisms of prospective payment systems which are premised primarily on the conflict between economic incentives to contain cost and the professional obligation of beneficence are probably as much a matter of rhetoric as serious argumentation. Keywords: autonomy, beneficence, cost containment, economic incentives, moral obligation, prospective payment CiteULike Connotea Del.icio.us What's this? (shrink)

Thomasma and Pellegrino''s [3] focus on the healing relationship as the way to give medical ethics a philosophical foundation contains a number of difficulties. Most importantly, their approach focuses philosophical analysis on an idealized view of the healing relationship in which the ideal of health is seen as an uncontroversial norm in the individual case. medical ethics is then characterized as an intrinsic part of the medical act itself. Philosophical inquiry seems limited to a description of the practice of medicine (...) in which ethical norms are embodied. Insufficient attention to methodology leaves unclear how this vision is to be achieved in philosophical reflection. (shrink)

In March 1997, 60 Minutes, a nationally syndicated news magazine program, featured a story in which it was claimed that The Cleveland Clinic Foundation had in place a non-heart-beating donor protocol that involved killing patients for their organs. These charges were brought by a philosopher from a local university. A student who worked at LifeBanc, the northeastern Ohio organ procurement agency where the organ donation protocol originated, was given the protocol by LifeBanc with the understanding that it was to be (...) used in class; the student and professor charged that the protocol involved killing patients for their organs. These claims were advanced without noting that the protocol was a draft that was being reviewed and revised and had not been implemented. (shrink)

This paper analyzes one dimension of the frequently alleged contradiction between treating medicine as a business and as a profession, namely the incompatibility between viewing the physician patient relationship in economic and moral terms. The paper explores the utilitarian foundations of economics and the deontological foundations of professional medical ethics as one source for the business/medicine conflict that influences beliefs about the proper understanding of the therapeutic relationship. It, then, focuses on the contrast and distinction between medicine as business and (...) profession by critically analyzing the classic economic view of the moral status of medicine articulated by Kenneth Arrow. The paper concludes with a discussion of some advantages associated with regarding medicine as a business. (shrink)

Method in ethics consultation has at least three distinguishable components: a canon – that is, the rules that guide actions, cognitions, judgments, and perceptions involved in performing an ethics consultation; a discipline – that is, a mastery, or at least possession, of the specific types of actions and intentions of ethics consultation which are guided by the rules that are embodied in the actions of competent ethics consultants; and a history – that is, the narrative of, and critical reflection on, (...) the actions, including the analyses, assessments, and communications undertaken in the course of the consultation, including the reasoning about the practical issues and the steps toward resolving the ethical question or issues that arose. As a doing, then, ethics consultation consists in actions and intentions that constitute a distinctive set of meanings in the clinical space of patient care in which the meanings brought to patient care through the actions and communications of the ethics consultation help shape, to some extent, the way that the case develops and is understood, which is further reflected in how the case is represented. In this sense, statements about ethics consultation methodology, and theories of ethics consultation, are secondary to the actual practice itself. The analysis and interpretation of actions and communications of those involved in the clinical care of the patient represents a complex process that blends the meaning of ethical concepts, principles, and theories with the constructed and uncovered clinical and value meanings of the case. (shrink)

Central to much medical ethical analysis is the concept of the role of the physician. While this concept plays an important role in medical ethics, its function is largely tacit. The present paper attempts to bring the concept of a social role to prominence by focusing on an historically recent and rather richly contextured role, namely, that of consultation liaison psychiatry. Since my intention is primarily theoretical, I largely ignore the empirical studies which purport to develop the detailed functioning of (...) the role. My limited intent is to draw attention to the theoretical complexity of the consultation liaison role as an example of the general relevance of role concepts to medical ethics. For this reason, consultation liaison psychiatry will function as an illustration of fundamental concepts of medical ethics rather than as a subject of analysis in its own right. Similarly, the concept of the social role will be developed only as is necessary to explore the general relationship between the consultation liaison role and ethical analysis. Keywords: medical ethics, consultation liaison psychiatry, social role, autonomy, institution CiteULike Connotea Del.icio.us What's this? (shrink)

Frank Koughan and Walt Bogdanich's response to my article, reminds me of the Shakespearean line, My article was not about the specifics of the 60Minutes April 13, 1997, story on NHBD at the Cleveland Clinic Foundation (CCF), even though the story formed the basis for the reflection. I did not attack the critics, though I do believe that bioethicists are accountable for their scholarly and public pronouncements. Although I do not see why the 60Minutes' story should be treated with deference, (...) my article was designed to raise questions for a primarily bioethics audience about the involvement of bioethicists in media coverage of bioethics topics. I am flattered that they took notice of my piece, but think their efforts to set the record straight only obfuscate matters further. (shrink)

This article discusses the approach of the Clinical Ethics Consultation Advisory Committee (CECA) in developing A Case-Based Study Guide for Addressing Patient-Centered Ethical Issues in Health Care. This article addresses the processes used by the CECA, its use of pivot questions intended to encourage critical reflection, and the target audience of this work. It first considers the salience of case studies in general education and their relevance for training ethics consultants. Second, it discusses the enfolding approach used in presenting the (...) case material designed to engage the trainee in the details of the case while stimulating critical reflection. And, third, this article briefly comments on the target audience with the caveat that even superbly developed cases are prone to misuse, although that prospect should not deter their development. (shrink)

This paper argues that the concept of management is critically important for understanding managed care. A proper interpretation of management is needed before a positive account of the ethics of managed care can be constructed. The paper discusses three aspects of management: administrative, clinical, and resource management, and compares the central commitments of traditional medical practice with those of managed care for each of these aspects. In so doing, the distinctive conceptual features of the managed care paradigm are discussed. The (...) paper concludes by arguing that the concept of management implicit in the managed care paradigm affords a basis for building a more adequate ethic of managed care. (shrink)