: The "difference position" holds that clinical research and therapeutic medical practice are sufficiently distinct activities to require different ethical rules and principles. The "similarity position" holds instead that clinical investigators ought to be bound by the same fundamental principles that govern therapeutic medicine—specifically, a duty to provide the optimal therapeutic benefit to each patient or subject. Some defenders of the similarity position defend it because of the overlap between the role of attending physician and the role of investigator in (...) a research trial. This overlap is maximal when the same physician occupies both roles with respect to a particular patient-subject. We address the ethical tensions inherent in that role conflict and argue that the tensions are real but manageable. The difference position provides a sound ethical framework within which to manage those tensions, while the similarity position is unsatisfactory because it seeks to deny the existence of the tensions. (shrink)

Some ethical issues facing contemporary medicine cannot be fully understood without addressing medicine's internal morality. Medicine as a profession is characterized by certain moral goals and morally acceptable means for achieving those goals. The list of appropriate goals and means allows some medical actions to be classified as clear violations of the internal morality, and others as borderline or controversial cases. Replies are available for common objections, including the superfluity of internal morality for ethical analysis, the argument that internal morality (...) is merely an apology for medicine's traditional power and authority, and the claim that there is no single, "core" internal morality. The value of addressing the internal morality of medicine may be illustrated by a detailed investigation of ethical issues posed by managed care. Managed care poses some fundamental challenges for medicine's internal morality, but also calls for thoughtful reflection and reconsideration of some traditionally held moral views on patient fidelity in particular. (shrink)

A special report of The Hastings Center and the Association of American Medical Colleges addressed the ethical oversight of learning health systems, which seek to combine high‐quality patient care with routine data collection aimed at improving patient outcomes. The report contained two position papers, authored by a number of distinguished bioethicists, and several commentaries. The position papers urged two changes. First, they urged a rethinking of our approach to the regulation of human subjects research, so as to make it easier (...) in the future for learning health systems to function well. Second, they argued that the rethinking required dispensing with a strict distinction between research and therapy, which has been a major tenet of bioethics since the Belmont Report, which explicated basic ethical principles governing human subjects research. We fully support the objectives of the authors, and we agree that the learning health system is an important advance that serves patients well. Unnecessary regulatory burden ought not impede this progress. We disagree, however, that the best way to bring about these needed changes in the regulatory environment is to reject the basic distinction between research and treatment. Unfortunately, we find the arguments in favor of that strategy to be, in places, reminiscent of what we take to be basic conceptual errors that hampered the ethical understanding of human subjects research prior to adoption of the Belmont Report. To see why one need not reject the research‐treatment distinction in order to promote learning health systems, we first investigate in some detail the arguments offered for eliminating the distinction. We next turn to an issue not addressed by those authors, namely, the relationship between the physician or investigator and the patient or subject, to illustrate why the distinction is important and what is lost if it is jettisoned. (shrink)

Cosmetic surgery is a fast-growing medical practice. In 1997 surgeons in the United States performed the four most common cosmetic procedures443,728 times, an increase of 150% over the comparable total for 1992. Estimated total expenditures for cosmetic surgery range from $1 to $2 billion. As managed care cuts into physicians' income and autonomy, cosmetic surgery, which is not covered by health insurance, offers a financially attractive medical specialty.

A predominant ethical view holds that physician‐investigators should conduct their research with therapeutic intent. And since a physician offering a therapy wouldn't prescribe second‐rate treatments, the experimental intervention and the best proven therapy should appear equally effective. "Clinical equipoise" is necessary. But this perspective is flawed. The ethics of research and of therapy are fundamentally different, and clinical equipoise should be abandoned.

The leading ethical position on placebo-controlled clinical trials is that whenever proven effective treatment exists for a given condition, it is unethical to test a new treatment for that condition against placebo. Invoking the principle of clinical equipoise, opponents of placebo-controlled trials in the face of proven effective treatment argue that they (1) violate the therapeutic obligation of physicians to offer optimal medical care and (2) lack both scientific and clinical merit. We contend that both of these arguments are mistaken. (...) Clinical equipoise provides erroneous ethical guidance in the case of placebo-controlled trials, because it ignores the ethically relevant distinction between clinical trials and treatment in the context of clinical medicine and the methodological limitations of active-controlled trials. Placebo controls are ethically justifiable when they are supported by sound methodological considerations and their use does not expose research participants to excessive risks of harm. (shrink)

A basic question of medical ethics is whether the norms governing medical practice should be understood as the application of principles and rules of the common morality to medicine or whether some of these norms are internal or proper to medicine. In this article we describe and defend an evolutionary perspective on the internal morality of medicine that is defined in terms of the goals of clinical medicine and a set of duties that constrain medical practice in pursuit of these (...) goals. This perspective is developed by means of a critical examination of the essentialist conception of the internal morality of medicine advocated by Edmund Pellegrino and the critique of internal morality approaches by Robert Veatch and Tom Beauchamp. (shrink)

The practice of voluntary physician‐assisted death as a last resort is compatible with doctors' duties to practice competently, to avoid harming patients unduly, to refrain from medical fraud, and to preserve patients' trust. It therefore does not violate physicians' professional integrity.

The doctrine of clinical equipoise is appealing because it appears to permit physicians to maintain their therapeutic obligation to offer optimal medical care to patients while conducting randomized controlled trials (RCTs). The appearance, however, is deceptive. In this article we argue that clinical equipoise is defective and incoherent in multiple ways. First, it conflates the sound methodological principle that RCTs should begin with an honest null hypothesis with the questionable ethical norm that participants in these trials should never be randomized (...) to an intervention known to be inferior to standard treatment. Second, the claim that RCTs preserve the therapeutic obligation of physicians misrepresents the patient-centered orientation of medical care. Third, the appeal to clinical equipoise as a basic principle of risk-benefit assessment for RCTs is incoherent. Finally, the difficulties with clinical equipoise cannot be resolved by viewing it as a presumptive principle subject to exceptions. In the final sections of the article, we elaborate on the non-exploitation framework for the ethics clinical research and indicate issues that warrant further inquiry. (shrink)

With breathtalung speed, traditional criminal prohibitions against assisted suicide have been declared unconstitutional in twelve states, including California and New York. This poses great promise and great peril. The promise is that competent terminally ill patients, as a compassionate measure of last resort, will have the option of putting an end to their suffering by physician-assisted suicide. More sigmficant, legally permitting this controversial option may be a catalyst for doctors, health care institutions, and society to improve the care of the (...) dying. PAS should be limited only to those relatively few competent patients who continue to suffer intolerably despite unrestrained efforts to palliate and who face a continued existence that they regard as worse than death. When dying patients know they will not be abandoned to miserable and pointless suffering if palliative care fails, they will be fortified to cope better with the process of dying.The immediate peril is that PAS will become a quick fix, available on demand to any patient diagnosed as terminally ill, thus bypassing palliative care and producing premature deaths. (shrink)

*The opinions expressed are the views of the author and do not necessarily reflect the policy of the National Institutes of Health, the Public Health Service, or the U.S. Department of Health and Human Services.

Realism in international relations theory is frequently understood to entail the abandonment or cynical manipulation of moral rules and principles. But realism has always been more than an amoral or immoral doctrine. More interesting versions of realism offer moral justifications for limiting the role of morality. We argue for a version of realism that flows from the function of the liberal democratic state as an indispensable condition of value. After setting out its central characteristics, we also argue that this liberal (...) democratic realism can adequately address four severe criticisms typically raised against realism in general. (shrink)

"Unlike most photographs of Eads Bridge, which are taken from a distance, Quinta Scott's intimate photographic essay shows the subtleties of form and texture that give this structure its remarkable aesthetic impact. Howard Miller's text complements the photos, explaining the place of James Eads's unorthodox design in the history of American architecture and aesthetics. Miller also explains the bridge's place in local and national economic history, describes its innovative engineering, and brings to life its unique creator."--Jacket.

We are drowning in information, while starving for wisdom.Are the smartest people also the wisest? Not necessarily. While traditional intellectual reasoning and procedural knowledge have helped build the communities we live in, there is a growing scientific understanding that we need emotionally balanced and better-fitting prosocial frameworks for coping with the uncertainties and complexities of life and addressing new challenges of the modern world. We are now poised on the edge of a new science of wisdom.The concept of wisdom, long (...) considered the “pinnacle of insight into the human condition”, has been that of an intangible, subjective, culturally specific entity—an unscientific... (shrink)

CHAPTER I POLITICAL FAITH AND UTOPIAN THOUGHT In the three and a half centuries since Bacon and the miller prayed for peace among the willows, countless men ...

In The Healer's Power, Howard Brody placed the concept of power at the heart of medicine's moral discourse. Struck by the absence of “power” in the prevailing vocabulary of medical ethics, yet aware of peripheral allusions to power in the writings of some medical ethicists, he intuited the importance of power from the silence surrounding it. He formulated the problem of the healer's power and its responsible use as “the central ethical problem in medicine.” Through the prism of power (...) he refracted a wide range of ethical problems, from informed consent to truth-telling, from confidentiality to futility, from the physician's fantasies to the physician's virtues. At times this prism shed new light on old problems, enabling us to see from an unexpected angle the elements of which the problem was composed. At other times it exposed issues of ethical significance that had been neglected in the bioethics literature. (shrink)

Like Henry Harris, I began doing intensive research on Hegel's Phenomenology of Spirit in the mid-sixties. I recall going through all the chapters as a graduate student during one academic year, and looking around for commentaries. The only English-language commentary available was Loewenberg's Hegel's Phenomenology: Dialogues in the Life of Mind, which was suggestive of the dialectic taking place in the book, but not much help in getting over the “rough spots”. This gave me an incentive to work through Jean (...) Hyppolite's commentary, not yet translated into English, with my basic reading-knowledge of French. My 1976 Hegel's Phenomenology, Part I: Analysis and Commentary was one of the first in a long line of Anglophone commentaries. Harris in his introduction to Vol. I. mentions this effort at “analysis”, along with Findlay's “analysis” accompanying the 1977 Miller translation of the Phenomenology, as incentives for the inclusion of his own improved running analysis in the present commentary. I have included discussions of numerous partial or complete commentaries on Hegel's Phenomenology in review articles published in 1971 in the American Philosophical Quarterly and Teorema, in 1979 in the American Philosophical Quarterly, and in 1981 in Hegel-Studien. Harris has the advantage of producing the most recent of all these commentaries, and in a way offers us a compendium of everything that has been done on the Phenomenology. His analysis and commentary includes a survey of the literature, in which almost all previous laborers in the field can find themselves commended or criticized in the endnotes. Thus I find comments like “Kainz has completely misunderstood the argument here”, “This is a point which Kainz has grasped more definitely than most commentators”, “[Kainz] does not deserve the brickbat Flay hurls at him”, and so forth. Other commentators, living and dead – Flay, Pöggeler, Navickas, Kenneth and Merold Westphal, Heidegger, Lauer, Werner Becker, Kojève, Wahl, Hyppolite, Labarrière, Bonsiepen, Forster, Shklar, Solomon, Werner Marx, and Robert Williams — are similarly discussed and critiqued. For some of us Anglophone commentators, such remarks may seem like red marks on essays from a patient professor. But certainly no one will mind, since Harris has spent more time and energy on this very specialized project than any of us. In fact, some former commentators almost have a “conflict of interest” in reviewing Harris' work, since so many of us have benefited at various points in our research from Harris' personal support and criticism. But in academics, as in life, mentors cannot always be assured of loyalty. (shrink)

Like Henry Harris, I began doing intensive research on Hegel's Phenomenology of Spirit in the mid-sixties. I recall going through all the chapters as a graduate student during one academic year, and looking around for commentaries. The only English-language commentary available was Loewenberg's Hegel's Phenomenology: Dialogues in the Life of Mind, which was suggestive of the dialectic taking place in the book, but not much help in getting over the “rough spots”. This gave me an incentive to work through Jean (...) Hyppolite's commentary, not yet translated into English, with my basic reading-knowledge of French. My 1976 Hegel's Phenomenology, Part I: Analysis and Commentary was one of the first in a long line of Anglophone commentaries. Harris in his introduction to Vol. I. mentions this effort at “analysis”, along with Findlay's “analysis” accompanying the 1977 Miller translation of the Phenomenology, as incentives for the inclusion of his own improved running analysis in the present commentary. I have included discussions of numerous partial or complete commentaries on Hegel's Phenomenology in review articles published in 1971 in the American Philosophical Quarterly and Teorema, in 1979 in the American Philosophical Quarterly, and in 1981 in Hegel-Studien. Harris has the advantage of producing the most recent of all these commentaries, and in a way offers us a compendium of everything that has been done on the Phenomenology. His analysis and commentary includes a survey of the literature, in which almost all previous laborers in the field can find themselves commended or criticized in the endnotes. Thus I find comments like “Kainz has completely misunderstood the argument here”, “This is a point which Kainz has grasped more definitely than most commentators”, “[Kainz] does not deserve the brickbat Flay hurls at him”, and so forth. Other commentators, living and dead – Flay, Pöggeler, Navickas, Kenneth and Merold Westphal, Heidegger, Lauer, Werner Becker, Kojève, Wahl, Hyppolite, Labarrière, Bonsiepen, Forster, Shklar, Solomon, Werner Marx, and Robert Williams — are similarly discussed and critiqued. For some of us Anglophone commentators, such remarks may seem like red marks on essays from a patient professor. But certainly no one will mind, since Harris has spent more time and energy on this very specialized project than any of us. In fact, some former commentators almost have a “conflict of interest” in reviewing Harris' work, since so many of us have benefited at various points in our research from Harris' personal support and criticism. But in academics, as in life, mentors cannot always be assured of loyalty. (shrink)

A letter to the editor from Howard Brody, David Buchanan, and Franklin G. Miller in response to the recent article by Erik Malmqvist Understanding Exploitation," March-April 2011).

After critiquing some earlier attempts (including those of Marcus Singer and Frances Howard–Snyder) to ground objections to actual–consequence act utilitarianism (ACAU) on human cognitive limitations, I present two new objections with this same foundation. Both start with the observation that, because human cognitive abilities are not up to the task of reliably recognizing utility–maximizing actions, any agents who are recognizably human – including the best possible humans, morally speaking – are certain to perform many actions every day that ACAU (...) says are immoral, and to perform some actions over the course of their lives that it says are highly immoral. The first objection is that, if Mill's analysis of what it means to call an action wrong is accurate, then ACAU entails a conclusion that no one will accept, viz., that the morally–best humans possible ought to undergo constant punishment. The second objection is that ACAU entails that even the morally–best humans possible are bad moral agents in some respect. This conclusion, while unpalatable, is not so obviously unacceptable as the first. However, I do briefly consider some ways in which it might be possible to demonstrate that it is false and thereby complete a reductio of ACAU. (shrink)

This book is collection of published and unpublished essays on the philosophy of religion by Howard Wettstein, who is a widely respected analytic philosopher. Over the past twenty years, Wettstein has attempted to reconcile his faith with his philosophy, and he brings his personal investment in this mission to the essays collected here. Influenced by the work of George Santayana, Wittgenstein, and A.J. Heschel, Wettstein grapples with central issues in the philosophy of religion such as the relationship of religious (...) practice to religious belief, what is at stake in the debate between atheists and theists, and the place of doctrine in religion. His discussions draw from Jewish texts as well as Christianity, Islam, and classical philosophy. The challenge Wettstein undertakes throughout the volume is to maintain a philosophical naturalism while pursuing an encounter with God and traditional religion. In the Introduction to this volume, Wettstein elucidates the uniting themes among the collected essays. (shrink)

An exploration of Immanuel Kant's account of war and the controversies that have arisen from its interpretation. This book brings the ideas of Kant's critical philosophy to bear on one of the leading political and legal questions of our age: under what circumstances, if any, is recourse to war legally and morally justifiable?

This book shows how the traditional concerns of political theory push it increasingly into the study of international relations. This is done, first, by demonstrating how many of the issues usually dealt with by political theory, such as democracy and justice, arise within an increasingly global context and, secondly, by considering how international issues, such as colonialism and war, are best illuminated by building on the work of political theorists. The book suggests that political theory and international relations theory can (...) now both be successfully engaged in as a joint enterprise only. (shrink)

The book is a comparative analysis of all the major social science/political science grand theories. It focuses on developmentalism, dependency theory, the world systems approach, Marxism, institutionalism, rational choice, psychoanalysis, political sociology, sociobiology, environmentalism, neuro-politics, transitions to democracy, and non-Western systems of analysis. To facilitate comparison and analysis, a common framework and outline are employed throughout. An integrating introduction and conclusion help tie the book together.

The Ethics of Need: Agency, Dignity, and Obligation argues for the philosophical importance of the notion of need and for an ethical framework through which we can determine which needs have moral significance. In the volume, Sarah Clark Miller synthesizes insights from Kantian and feminist care ethics to establish that our mutual and inevitable interdependence gives rise to a duty to care for the needs of others. Further, she argues that we are obligated not merely to meet others’ needs (...) but to do so in a manner that expresses "dignifying care," a concept that captures how human interactions can grant or deny equal moral standing and inclusion in a moral community. She illuminates these theoretical developments by examining two cases where urgent needs require a caring and dignifying response: the needs of the elderly and the needs of global strangers. Those working in the areas of feminist theory, women’s studies, aging studies, bioethics, and global studies should find this volume of interest. (shrink)

Modes-of-being figure centrally in Heidegger's masterwork Being and Time. Testimony to this is Heidegger's characterisation of two of his most celebrated enquiries—the Existential analytic and the Zeug analysis—as investigations into the respective modes-of-being of the entities concerned. Yet despite the importance of this concept, commentators disagree widely about what a mode-of-being is. In this paper, I systematically outline and defend a novel and exegetically grounded interpretation of this concept. Strongly opposed to Kantian readings, such as those advocated by Taylor Carman (...) and Cristina Lafont, I interpret a mode-of-being as a universal that defines a district —that is, a natural class of entities that ought to be conceptualised in a special way. As such, every mode-of-being plays an important metaphysical and epistemic role: serving both to unify a natural class of a high degree of generality and as the interpretandum of an act yielding the basic-concepts pertaining to the entities therein. In explicating and arguing for this interpretation, I attribute a characteristically Aristotelian philosophical position to the early Heidegger, encompassing both metaphysical and epistemological realism and a conceptualist theory of universals. (shrink)

A startling look at one of this century's most influential philosophers, the book chronicles every stage of Foucault's personal and professional odyssey, from his early interest in dreams to his final preoccupation with sexuality and the nature of personal identity.

This chapter outlines the main ideas of my book National responsibility and global justice. It begins with two widely held but conflicting intuitions about what global justice might mean on the one hand, and what it means to be a member of a national community on the other. The first intuition tells us that global inequalities of the magnitude that currently exist are radically unjust, while the second intuition tells us that inequalities are both unavoidable and fair once national responsibility (...) is allowed to operate. This conflict might be resolved either by adopting a cosmopolitan theory of justice (which leaves no room for national responsibility) or by adopting a ?political? theory of justice (which denies that questions of distributive justice can arise beyond the walls of the sovereign state). Since neither resolution is satisfactory, the chapter defends the idea of national responsibility and proposes a new theory of global justice, whose main elements are the protection of basic human rights worldwide, and fair terms of interaction between independent political communities. (shrink)

The loss of the federally protected constitutional right to an abortion is a threat to the already tenuous autonomy of pregnant people, and may augur future challenges to their right to refuse unwanted obstetric interventions. Even before Roe’s demise, pregnancy led to constraints on autonomy evidenced by clinician-led legal incursions against patients who refused obstetric interventions. In Dobbs v. Jackson Women’s Health Organization, the Supreme Court found that the right to liberty espoused in the Constitution does not extend to a (...) pregnant person’s right to an abortion. With Roe’s demise, the right to request specific types of care has been vitiated. The same argument underpinning that holding may now become ballast for attacks on the traditionally more robust right, the right to refuse. Here we discuss how the elevation of fetal and embryonic rights may lead to a cascade of medical intrusions and deprivations of liberty against pregnant persons, and offer an argument opposing these improprieties. (shrink)

This article serves as either an addendum or as an expansion of ideas and work developed in my 2024 book, The Rationality Project: Across the Millennia, issued by Palgrave Macmillan. The book explores 21 potential theories for explaining rationality in terms of why and how one among these can serve in the position of explanatory power. The book does not fully explain all of these candidate theories, assigning that complete role to this addendum or work-in-progress. The main reason for this (...) abbreviation in assessing all the theories in the book is that the complete coverage—which this addendum allows—of all 21 theories would become too detailed for some philosophical readers. This addendum; one may consider, is then for the more technically minded reader—although certainly not-too-technically minded readers are welcome to explore it. If it becomes too bogged in detail for those latter kinds of readers, they may end up skimming the material in this addendum, trying at least to get the general idea of how these addendum sections fit into the book's goals. (shrink)