There is a growing body of writing, for instance from the nursing profession, espousing an approach to ethics based on care. I suggest that this approach is hopelessly vague and that the vagueness is due to an inadequate analysis of the concept of care. An analysis of 'care' and related terms suggests that care is morally neutral. Caring is not good in itself, but only when it is for the right things and expressed in the right way. 'Caring' ethics assumes (...) wrongly that caring is good, thus it can tell us neither what constitutes those right things, nor what constitutes the right way. (shrink)

This article aims: (1) to introduce the wider philosophy of Aristotle to nurses and healthcare practitioners; (2) to show that Aristotle's philosophical system is an interdependent whole; and (3) to defend its plausibility and usefulness despite its ancient and alien origins.Aristotle's system can be set out as a hierarchy, with metaphysics at the top and methodology running throughout. Beneath metaphysics are the sciences, with theoretical, practical and productive (or craft) sciences in hierarchical order. This hierarchy does not imply that, say, (...) metaphysics is superior to biology or nursing, but rather that metaphysics can be understood without reference to the other two but, as we shall see, not vice versa.Two themes run through Aristotelian philosophy. The first is Aristotle's method of inquiry, central to which is that our starting point is not pure empirical data, but rather current puzzles; complementing this method is a realist philosophy. The second theme is teleology, the understanding of action in the world in terms of ends, as when we say a plant grows roots to reach water and nutrients.Implications for nursing. Good health is the good functioning of the material aspect of humans; flourishing is good functioning of humans per se. The goals of nursing, which are based on health, are subsumed by the overall human goal of flourishing, and this helps us to understand and set boundaries to health care. Two examples illustrate this. The first is that mental illness is strongly within the purview of nursing and health care whereas bad decisions, such as smoking, are only marginally so. The second is ethics, where it is argued that the attempt to describe ethical decision‐making as in addition to and separate from the decisions made within nursing and health care itself cannot be sustained. (shrink)

The purpose of this article is to develop a conception of death with dignity and to examine whether it is vulnerable to the sort of criticisms that have been made of other conceptions. In this conception “death” is taken to apply to the process of dying; “dignity” is taken to be something that attaches to people because of their personal qualities. In particular, someone lives with dignity if they live well (in accordance with reason, as Aristotle would see it). It (...) follows that health care professionals cannot confer on patients either dignity or death with dignity. They can, however, attempt to ensure that the patient dies without indignity. Indignities are affronts to human dignity, and include such things as serious pain and the exclusion of patients from involvement in decisions about their lives and deaths. This fairly modest conception of death with dignity avoids the traps of being overly subjective or of viewing the sick and helpless as “undignified”. (shrink)

Objective: To assess whether continuous consent, a process in which information is given to research participants at different stages in a trial, and clinician training in that process were effective when used by clinicians while gaining consent to the Total Body Hypothermia (TOBY) trial. The TOBY trial is a randomised controlled trial (RCT) investigating the use of whole-body cooling for neonates with evidence of perinatal asphyxia. Obtaining valid informed consent for the TOBY trial is difficult, but is a good test (...) of the effectiveness of continuous consent. Methods: Semistructured interviews were conducted with 30 sets of parents who consented to the TOBY trial and with 10 clinicians who sought it by the continuous consent process. Analysis was focused on the validity of parental consent based on the consent components of competence, information, understanding and voluntariness. Results: No marked problems with consent validity at the point of signature were observed in 19 of 27 (70%) couples. Problems were found mainly to lie with the competence and understanding of the parents: mothers, particularly, had problems with competence in the early stages of consent. Problems in understanding were primarily to do with side effects. Problems in both competence and understanding were observed to reduce markedly, particularly for mothers, in the post-signature phase, when further discussion took place. Randomisation was generally understood but unpopular. Information was not always given by clinicians in stages during the short period available before parents gave consent. Most clinicians, however, were able to give follow-up information. Discussion: Consent validity was found to compare favourably with similar trials examined in the Euricon study. Conclusion: Adopting the elements of the continuous consent process and clinician training in RCTs should be considered by researchers, particularly when they have concerns about the quality of consent they are likely to obtain by using a conventional process. (shrink)

In this paper, we consider three arguments for the irrelevance of the doctrine of double effect in end-of-life decision making. The third argument is our own and, to that extent, we seek to defend it. The first argument is that end-of-life decisions do not in fact shorten lives and that therefore there is no need for the doctrine in justification of these decisions. We reject this argument; some end-of-life decisions clearly shorten lives. The second is that the doctrine of double (...) effect is not recognized in UK law ; therefore, clinicians cannot use it as the basis for justification of their decisions. Against this we suggest that while the doctrine might have dubious legal grounds, it could be of relevance in some ways, e.g. in marking the boundary between acceptable and unacceptable practice in relation to the clinician's duty to relieve pain and suffering. The third is that the doctrine is irrelevant because it requires there to be a bad effect that needs justification. This is not the case in end-of-life care for patients diagnosed as dying. Here, bringing about a satisfactory dying process for a patient is a good effect, not a bad one. What matters is that patients die without pain and suffering. This marks a crucial departure from the double-effect doctrine; if the patient's death is not a bad effect then the doctrine is clearly irrelevant. A diagnosis of dying allows clinicians to focus on good dying and not to worry about whether their intervention affects the time of death. For a patient diagnosed as dying, time of death is rarely important. In our conclusion we suggest that acceptance of our argument might be problematic for opponents of physician-assisted death. We suggest one way in which these opponents might argue for a distinction between such practice and palliative care; this relies on the double-effect doctrine's distinction between foresight and intention. (shrink)

Virtue ethics is often proposed as a third way in health‐care ethics, that while consequentialism and deontology focus on action guidelines, virtue focuses on character; all three aim to help agents discern morally right action although virtue seems to have least to contribute to political issues, such as austerity. I claim: This is a bad way to characterize virtue ethics. The 20th century renaissance of virtue ethics was first proposed as a response to the difficulty of making sense of ‘moral (...) rightness’ outside a religious context. For Aristotle the right action is that which is practically best; that means best for the agent in order to live a flourishing life. There are no moral considerations besides this. Properly characterized, virtue ethics can contribute to discussion of austerity. A criticism of virtue ethics is that fixed characteristics seem a bad idea in ever‐changing environments; perhaps we should be generous in prosperity, selfish in austerity. Furthermore, empirical evidence suggests that people indeed do change with their environment. However, I argue that virtues concern fixed values not fixed behaviour; the values underlying virtue allow for different behaviour in different circumstances: in austerity, virtues still give the agent the best chance of flourishing. Two questions arise. In austere environments might not injustice help an individual flourish by, say, obtaining material goods? No, because unjust acts undermine the type of society the agent needs for flourishing. What good is virtue to those lacking the other means to flourish? The notion of degrees of flourishing shows that most people would benefit somewhat from virtue. However, in extreme circumstances virtue might harm rather than benefit the agent: such circumstances are to be avoided; virtue ethics thus has a political agenda to enable flourishing. This requires justice, a fortiori when in austerity. (shrink)

Randomised controlled trials (RCTs) sometimes recruit participants who are desperate to receive the experimental treatment. This paper defends the practice against three arguements that suggest it is unethical first, desperate volunteers are not in equipoise. Second clinicians, entering patients onto trials are disavowing their therapeutic obligation to deliver the best treatment; they are following trial protocols rather than delivering individualised care. Research is not treatment; its ethical justification is different. Consent is crucial. Third, desperate volunteers do not give proper consent: (...) effectively, they are coerced. This paper responds by advocating a notion of equipoise based on expert knowledge and widely shared values. Where such collective, expert equipoise exists there is a prima facie case for an RCT. Next the paper argues that trial entry does not involve clinicians disavowing their therapeutic obligation; individualised care based on insufficient evidence is not in patients best interest. Finally, it argues that where equipoise exists it is acceptable to limit access to experimental agents; desperate volunteers are not coerced because their desperation does not translate into a right to receive what they desire. (shrink)

This article claims that health promotion is best practised in the light of an Aristotelian conception of the good life for humans and of the place of health within it.

The main claim of this paper is that the method outlined and used in Aristotle’s Ethics is an appropriate and credible one to use in bioethics. Here “appropriate” means that the method is capable of establishing claims and developing concepts in bioethics and “credible” that the method has some plausibility, it is not open to obvious and immediate objection. It begins by suggesting why this claim matters and then gives a brief outline of Aristotle’s method. The main argument is made (...) in three stages. First, it is argued that Aristotelian method is credible because it compares favourably with alternatives. In this section it is shown that Aristotelian method is not vulnerable to criticisms that are made both of methods that give a primary place to moral theory (such as utilitarianism) and those that eschew moral theory (such as casuistry and social science approaches). As such, it compares favourably with these other approaches that are vulnerable to at least some of these criticisms. Second, the appropriateness of Aristotelian method is indicated through outlining how it would deal with a particular case. Finally, it is argued that the success of Aristotle’s philosophy is suggestive of both the credibility and appropriateness of his method. (shrink)

Clinicians are required to act in the best interest of neonates.However, it is not obvious that entry into a randomised controlled trial (RCT) is in a neonate’s best interest because such trials often involve additional onerous procedures (such as intramuscular injections) in return for which the neonate receives unproven treatment or a placebo.On the other hand, neonatology needs to develop its evidence base, and RCTs are central to this task. The solution posited here is based on two points. First, “best (...) interest” is not equivalent to “the best possible interest” only to “best interest within a certain realm”. The realm of deliberation when asking the title question is the neonate’s health. Deliberating in this realm may involve the exclusion from consideration of some factors that might be thought relevant (such as parental wealth). Furthermore, circumstances may dictate the need to deliberate on other factors that might be thought irrelevant (such as health care resources). Second, deciding on a neonate’s best interest does not involve “putting oneself in its shoes”. Rather, it involves asking in what it has an interest, or stake. These will include some things in which we all, as human beings, have a stake, such as medical progress. Putting these two points together, in the realm of health the answer to whether RCT entry is in a neonate’s best interest is usually very finely balanced. Where this is the case, it is reasonable to invoke a broader notion of best interest and include a broader range of elements in which the neonate has a stake, including medical progress. In this way RCT entry can, usually, be said to be in a neonate’s best interest. (Journal of Medical Ethics 2001;27:110–113) Keywords: Neonates; randomised controlled trials; best interest; ethics. (shrink)

Recent research governance documents say that the body of research evidence must reflect population diversity. The response to this needs to be more sophisticated than simply ensuring minorities are present in samples. For quantitative research looking primarily at treatment effects of drugs and devices four suggestions are made. First, identify where the representation of minorities in samples matters—for example, where ethnicity may cause different treatment effects. Second, where the representation of a particular group matters then subgroup analysis of the results (...) will usually be necessary. Third, ensuring representation and subgroup analysis will have costs; deciding on whether such representation is worthwhile will involve cost benefit analysis. Fourth, the representation of minorities should not be seen as mainly a locality issue. For qualitative research it is argued that the representation of diversity is often important. Given the small samples of many qualitative projects, however, the best way to ensure representation occurs is to allow a proliferation of such research, not to stipulate such representation in samples. (shrink)

The purpose of this article is to set out an Aristotelian account of individual autonomy. Individual autonomy is the capacity of the individual to make and act upon judgments for which he is held morally accountable. This sense of autonomy may be contrasted to a number of other senses. Of these, the most important are political or legal autonomy and Kantian principled autonomy. Political or legal autonomy concerns the environment in which an individual operates. It exists where individuals are able (...) to operate reasonably freely.1 For the most part we will not consider this sense except insofar as it is necessary to explain the importance placed on respecting individual autonomy. Kantian principled autonomy has been described recently by Onora O‟Neill in a series of writings.2 On this account, autonomy is seen as a characteristic of the principle behind action rather than of action per se and is not a characteristic of agents at all. (shrink)

This paper reports a literature review on the topic of ethical issues in in-depth interviews. The review returned three types of article: general discussion, issues in particular studies, and studies of interview-based research ethics. Whilst many of the issues discussed in these articles are generic to research ethics, such as confidentiality, they often had particular manifestations in this type of research. For example, privacy was a significant problem as interviews sometimes probe unexpected areas. For similar reasons, it is difficult to (...) give full information of the nature of a particular interview at the outset, hence informed consent is problematic. Where a pair is interviewed (such as carer and cared-for) there are major difficulties in maintaining confidentiality and protecting privacy. The potential for interviews to harm participants emotionally is noted in some papers, although this is often set against potential therapeutic benefit. As well as these generic issues, there are some ethical issues fairly specific to in-depth interviews. The problem of dual role is noted in many papers. It can take many forms: an interviewer might be nurse and researcher, scientist and counsellor, or reporter and evangelist. There are other specific issues such as taking sides in an interview, and protecting vulnerable groups. Little specific study of the ethics of in-depth interviews has taken place. However, that which has shows some important findings. For example, one study shows participants are not averse to discussing painful issues provided they feel the study is worthwhile. Some papers make recommendations for researchers. One such is that they should consider using a model of continuous (or process) consent rather than viewing consent as occurring once, at signature, prior to the interview. However, there is a need for further study of this area, both philosophical and empirical. (shrink)

My original paper suggested that an ethics of care which failed to specify how, and about what, to care would be devoid of normative and descriptive content. Bradshaw's approach provides such a specification and is, therefore, not devoid of such content. However, as all ethical approaches suggest something about the 'what' and 'how' of care, they are all 'ethics of care' in this broader sense. This reinforces rather than undermines my original conclusion. Furthermore, Bradshaw's 'ethics of care' has philosophical and (...) historical problems which I outline. (shrink)

It is argued in this paper that the latest UK government white paper on public health, Choosing Health, is vulnerable to a charge of paternalism. For some years libertarians have levelled this charge at public health policies. The white paper tries to avoid it by constant reference to informed choice and choice related terms. The implication is that the government aims only to inform the public of health issues; how they respond is up to them. It is argued here, however, (...) that underlying the notion of informed choice is a Kantian, ‘‘inner citadel’’ view of autonomy. According to this view, each of us acts autonomously only when we act in accord with reason. On such a view it is possible to justify coercing, cajoling, and conning people on the basis that their current behaviour is not autonomous because it is subject to forces that cause irrational choice, such as addiction. ‘‘Informed choice’’ in this sense is compatible with paternalism. This paternalism can be seen in public health policies such as deceptive advertising and the treatment of ‘‘bad habits’’ as addictions. Libertarians are bound to object to this. In the concluding section, however, it is suggested that public health can, nonetheless, find ethical succour from alternative approaches. (shrink)

“Lay epidemiology” is a term used to describe the processes through which health risks are understood and interpreted by laypeople. It is seen as a barrier to public health when the public disbelieves or fails to act on public health messages. Two elements to lay epidemiology are proposed: empirical beliefs about the nature of illness and values about the place of health and risks to health in a good life. Both elements have to be dealt with by effective public health (...) schemes or programmes, which would attempt to change the public’s empirical beliefs and values. This is of concern, particularly in a context in which the lay voice is increasingly respected. Empirically, the scientific voice of standard epidemiology should be deferred to by the lay voice, provided a clear distinction exists between the measurement of risk, which is empirical, and its weighting, which is based on values. Turning to engagement with values, health is viewed to be an important value and is discussed and reflected on by most people. Public health professionals are therefore entitled and advised to participate in that process. This view is defended against some potential criticisms. (shrink)

Science seems to develop by inducing new knowledge from observation. However, it is hard to find a rational justification for induction. Popper offers one attempt to resolve this problem. Nursing theorists have tended to ignore or reject Popper, often on the false belief that he is a logical positivist (and hence hostile to qualitative research). Logical positivism claims that meaningful sentences containing any empirical content should ultimately be reducible to simple, observation statements. Popper refutes positivism by showing that there are (...) no such simple statements. He is not a positivist. For Popper, the scientist begins with problems and puts forward trial solutions. These are subjected to rigorous testing aimed at falsifying them. A new theoretical position is then reached in which the scientist knows either that the trial solutions are false or that they have not yet been falsified. Science is characterized by the fact that it tests its ideas through attempted falsification. Nonscience tests its ideas through attempted refutation. Nursing theory is a mixture of science and non-science. Popper’s method requires rigorous testing of theory in both realms. As such, some nursing theory should be discarded. Popper’s view faces at least two important criticisms. One is that a scientist can always reject an apparent falsification by instead altering some auxiliary hypothesis (e.g. denying the accuracy of the falsifying observation). Popper can deal with this argument by saying that defence of a theory in this way will eventually break down if the theory is false. The second criticism is that Popper’s method does ultimately draw upon induction. This criticism is true, but his method can be usefully adapted. An adapted from of Popper’s philosophy of science provides a good basis for nursing theory. (shrink)

People with severe learning disability are particularly difficult to include in the research process. As a result, researchers may be tempted to focus on those with learning disability who can be included. The problem is exacerbated in this field as the political agenda of inclusion and involvement is driven by those people with learning disability who are the higher functioning. To overcome this we should first detach the notion of consent from ideas about autonomy and think instead of it as (...) a way to avoid wronging others; this fits the original historical use of consent in research. This allows us to think in terms of including participants to the best of their abilities rather than in terms of a threshold of autonomy. Researchers could then use imaginative ways to include the least able and to ensure they are not wronged in research or by exclusion from it. (shrink)

In the August riots in England 2011, web sites provided up-to-date access to bare witness to the unsettling events that conveyed the essence of contemporary war and crisis reporting. These characteristics include events happening in real time, dramatic accounts, continuous coverage and multimedia footage, with also the inclusion of eyewitness stories and images. The rhetoric of war was used and dramatic photographs played a pivotal role in conveying the civil unrest as a ‘war zone.’ Significantly, the local environment becomes the (...) place for potential trauma, but also a space where the spectacle of violence, destruction, as well as community spirit are foregrounded. This article examines the background to the riots and the vernacular of war photography and the cultural landscape civil unrest and urban space. (shrink)

Bayes’ rule shows how one might rationally change one’s beliefs in the light of evidence. It is the foundation of a statistical method called Bayesianism. In health care research, Bayesianism has its advocates but the dominant statistical method is frequentism. There are at least two important philosophical differences between these methods. First, Bayesianism takes a subjectivist view of probability (i.e. that probability scores are statements of subjective belief, not objective fact) whilst frequentism takes an objectivist view. Second, Bayesianism is explicitly (...) inductive (i.e. it shows how we may induce views about the world based on partial data from it) whereas frequentism is at least compatible with non-inductive views of scientific method, particularly the critical realism of Popper. Popper and others detail significant problems with induction. Frequentism’s apparent ability to avoid these, plus its ability to give a seemingly more scientific and objective take on probability, lies behind its philosophical appeal to health care researchers. However, there are also significant problems with frequentism, particularly its inability to assign probability scores to single events. Popper thus proposed an alternative objectivist view of probability, called propensity theory, which he allies to a theory of corroboration; but this too has significant problems, in particular, it may not successfully avoid induction. If this is so then Bayesianism might be philosophically the strongest of the statistical approaches. The article sets out a number of its philosophical and methodological attractions. Finally, it outlines a way in which critical realism and Bayesianism might work together. (shrink)

My aim is to suggest that there is a case for using a randomised consent design in some neonatal trials. As an example I use the trials of extracorporeal membrane oxygenation (ECMO) in neonates suffering pulmonary hypertension. In some trials the process of obtaining consent has the potential to harm the subject, for example, by disappointing those who end in the control group and by creating additional anxiety at times of acute illness. An example of such were the trials of (...) extracorporeal membrane oxygenation (ECMO) in neonates suffering pulmonary hypertension. Pre-randomised consent could avoid or lessen these harms. However, a number of ethical objections are made to these research designs. They involve denial of information, using people, denial of choice, and "overselling" of allocated treatment. Furthermore, they are the wrong response; better communication might be the answer, for example. I argue that these objections are not completely persuasive. However, they are enough to suggest caution in the use of such designs. (shrink)