This article deals with two types of Christian faith in the light of the challenges posed by the ethics of belief. It is proposed that the difficulties with Clifford’s formulation of that ethic can best be handled if the ethic is interpreted in terms of role-specific intellectual integrity. But the ethic still poses issues for the traditional interpretation of Christian faith when it is conceived as a series of discrete but related propositions, especially historical propositions. For as so conceived, the (...) believer makes claims that fall within the province of an intellectual discipline, history, that requires evidence and rules of procedure for the adjudication of such claims. It is noteworthy how few Christian theologians and philosophers of religion deal with the issue in these terms. Alvin Plantinga is a noteworthy exception and his views are examined and criticized because, among other things, his conclusion is that any believer without having any training in biblical languages or historical studies can know that the New Testament narratives are true. The article then considers a second conception of Christian faith in which this conflict does not arise. One finds it in the works of Schleiermacher, Wittgenstein, and, surprisingly, in the conception of faith found in the early writings of Karl Barth. (shrink)

BackgroundAs moral case deliberations (MCDs) have increasingly been implemented in health care institutions as a form of ethics support, it is relevant to know whether and how MCDs actually contribute to positive changes in care. Insight is needed on what actually happens in daily care practice following MCD sessions. This study aimed at investigating the impact of MCD and exploring how ‘impact of MCD’ should be conceptualized for future research.MethodsA multiple-case study was conducted in a care organization for people with (...) intellectual disabilities and/or acquired brain injury, by observing MCD sessions as ‘cases’, followed by interviews with health care professionals concerning the follow-up to these cases, and a focus group with involved MCD facilitators. A conceptual scheme concerning the possible impact formed the basis for analysis: (1) individual moral awareness; (2) the actions of health care professionals; (3) collaboration among health care professionals; (4) the concrete situation of the client; (5) the client’s quality of care and life; (6) the organizational and policy level.ResultsAccording to interviewees, their moral awareness and their collaboration, both among colleagues and with clients’ relatives, improved after MCD. Perceived impact on client situation, quality of care/life and the organizational level varied among interviewees or was difficult to define or link to MCD. Three aspects were added to the conceptual scheme concerning the impact of MCD: (a) preparations and expectations prior to the MCD session; (b) a translational step between the conclusions of the MCD session and practical events in the following period, and (c) collaboration with clients’ relatives. A negative impact of MCD was also found on misunderstandings among participants and disappointment about lack of follow-up.ConclusionsConcretizing and conceptualizing the ‘impact’ of MCD is complicated as many factors play a role either before or during the transition from MCD to practice. It is important to consider ‘impact’ in a broad sense and to relate it to the goals and context of the MCD in question. Future studies in this field should pay additional attention to the preparations, content and process involved in ethics support, including clients’ and relatives’ experiences. (shrink)

Background Notwithstanding the need to produce evidence-based knowledge on medications for pregnant women, they remain underrepresented in clinical research. Sometimes they are excluded because of their supposed vulnerability, but there are no universally accepted criteria for considering pregnant women as vulnerable. Our aim was to explore whether and if so to what extent pregnant women are vulnerable as research subjects. Method We performed a conceptual and empirical analysis of vulnerability applied to pregnant women. Analysis A conceptual analysis supports Hurst's definition (...) of vulnerability. Consequently, we argue that pregnant women are vulnerable if they encounter an identifiably increased likelihood of incurring additional or greater wrong. According to the literature, this increased likelihood could exist of four alleged features for pregnant women's vulnerability: informed consent, susceptibility to coercion, higher exposure to risk due to lack of knowledge, vulnerability of the fetus. Discussion Testing the features against Hurst's definition demonstrates that they all concern the same issue: pregnant women are only vulnerable because a higher exposure to risk due to lack of scientific knowledge comprises an increased wrong. Research Ethics Committees have a responsibility to protect the vulnerable, but a higher exposure to risk due to lack of scientific knowledge is a much broader issue and also needs to be addressed by other stakeholders. Conclusions The only reason why pregnant women are potentially vulnerable is to the extent that they are increasingly exposed to higher risks due to a lack of scientific knowledge. Accordingly, the discussion can advance to the development of practical strategies to promote fair inclusion of pregnant women in clinical research. (shrink)

Two decades of research on euthanasia in the Netherlands have resulted into clear insights in the frequency and characteristics of euthanasia and other medical end-of-life decisions in the Netherlands. These empirical studies have contributed to the quality of the public debate, and to the regulating and public control of euthanasia and physician-assisted suicide. No slippery slope seems to have occurred. Physicians seem to adhere to the criteria for due care in the large majority of cases. Further, it has been shown (...) that the majority of physicians think that the euthanasia Act has improved their legal certainty and contributes to the carefulness of life-terminating acts. In 2005, eighty percent of the euthanasia cases were reported to the review committees. Thus, the transparency envisaged by the Act still does not extend to all cases. Unreported cases almost all involve the use of opioids, and are not considered to be euthanasia by physicians. More education and debate is needed to disentangle in these situations which acts should be regarded as euthanasia and which should not. Medical end-of-life decision-making is a crucial part of end-of-life care. It should therefore be given continuous attention in health care policy and medical training. Systematic periodic research is crucial for enhancing our understanding of end-of-life care in modern medicine, in which the pursuit of a good quality of dying is nowadays widely recognized as an important goal, in addition to the traditional goals such as curing diseases and prolonging life. (shrink)

In this paper, we examine how organizations’ impression management evolves in response to rising stakeholder pressures regarding organizations’ corporate responsibility initiatives. We conducted a comparative case study analysis over a period of 13 years for two organizations—Exxon and BP—that took extreme initial stances on climate change. We found that as stakeholder pressures rose, their IM tactics unfolded in four phases: advocating the initial stance, sensegiving to clarify the initial stance, image repairing, and adjusting the stance. Taken together, our analysis of (...) IM over these four phases provides three key insights about the evolution of IM in the face of rising pressures. First, when faced with stakeholder pressures, it seems that organizations do not immediately resort to conforming but tend to give in gradually when pressures increase and start to come from relatively powerful stakeholders. Second, evolution of IM seems to be characterized by path dependence, i.e., even as organizations’ positions evolve, they continue to show their conviction in their initial positions and try to convey that their subsequent positions flow logically from the previous ones. Finally, IM involves navigation between symbolism and substance, and companies tend to strive toward harmonizing their symbolic and substantive actions as stakeholder pressure increases. (shrink)

Legal and moral reasoning share much methodology, and they address similar problems. This volume charts two shared problems: the relation between theory, principles and particular judgments; and the role of facts and factual assertions in normative settings. The relation between 'theory' and 'practice' and between 'principle' and 'particular judgment' has become the subject of much debate in moral philosophy. In the ongoing debate, some moral philosophers refer to legal philosophy for a support of their views on the primacy of 'practice' (...) over 'theory'. According to them, legal philosophy should have a more balanced view in that relation. In the contributions to Part One this claim is critically analysed. The role of the facts is underestimated in discussions on legal reasoning and legal theory, as well as moral reasoning and ethical theory. Factual statements enter into moral and legal discussions not only because they link the conclusion with a rule. They also play a role as background assumptions in supporting a theory. Its focus on the role of facts in normative reasoning makes this book of special interest to scholars of legal and moral argumentation. (shrink)

We give in this paper a sufficient condition, cast in semantic terms, for Hallden-completeness in normal modal logics, a modal logic being said to be Hallden-complete (or Ήallden-reasonable') just in case for any disjunctive formula provable in the logic, where the disjuncts have no propositional variables in common, one or other of those disjuncts is provable in the logic.

There is ambiguity with regard to what counts as an acceptable level of risk in clinical research in pregnant women and there is no input from stakeholders relative to such research risks. The aim of our paper was to explore what stakeholders who are actively involved in the conduct of clinical research in pregnant women deem an acceptable level of risk for pregnant women in clinical research. Accordingly, we used the APOSTEL VI study, a low-risk obstetrical randomised controlled trial, as (...) a case-study. We conducted a prospective qualitative study using 35 in-depth semi-structured interviews and one focus group. We interviewed healthcare professionals, Research Ethics Committee members and regulators who are actively involved in the conduct of clinical research in pregnant women, in addition to pregnant women recruited for the APOSTEL VI case-study in the Netherlands. Three themes characterise the way stakeholders view risks in clinical research in pregnant women in general. Additionally, one theme characterises the way healthcare professionals and pregnant women view risks with respect to the case-study specifically. First, ideas on what constitutes an acceptable level of risk in general ranged from a preference for zero risk for the foetus up to minimal risk. Second, the desirability of clinical research in pregnant women in general was questioned altogether. Third, stakeholders proposed to establish an upper limit of risk in potentially beneficial clinical research in pregnant women in order to protect the foetus and the pregnant woman from harm. Fourth and finally, the case-study illustrates that healthcare professionals’ individual perception of risk may influence recruitment. Healthcare professionals, RECs, regulators and pregnant women are all risk adverse in practice, possibly explaining the continuing underrepresentation of pregnant women in clinical research. Determining the acceptable levels of risk on a universal level alone is insufficient, because the individual perception of risk also influences behaviour towards pregnant women in clinical research. Therefore, bioethicists and researchers might be interested in changing the perception of risk, which could be achieved by education and awareness about the actual benefits and harms of inclusion and exclusion of pregnant women. (shrink)

Objectives: To analyse and compare the surveys on German doctors and judges on end of life decision making regarding their attitudes on the advance directive and on the dying process.Design: The respondents were to indicate their agreement or disagreement to eight statements on the advance directive and to specify their personal view on the beginning of the dying process.Participants: 727 doctors in three federal states and 469 judges dealing with guardianship matters all over Germany.Main measurements: Comparisons of means, analyses of (...) variance, pivot tables and factor analyses .Results: Three attitude groups on advance directive were disclosed by the analysis: the decision model, which emphasises the binding character of a situational advance directive; the deliberation model, which puts more emphasis on the communicative aspect; and the delegation model, which regards the advance directive as a legal instrument. The answers regarding the beginning of the dying process were broadly distributed, but no marked difference was observed between the responding professions. The dying process was assumed by most participants to begin with a life expectancy of only a few days.Conclusions: A high degree of valuation for advance directive was seen in both German doctors and judges; most agreed to the binding character of the situational directive. Regarding the different individual concepts of the dying process, a cross-professional discourse on the contents of this term seems to be overdue. (shrink)

In this article we discuss the ethical dilemmas facing performance evaluators and the "evaluatees" whose performances are measured in a business context. The concepts of role morality and common morality are used to develop a framework of behaviors that are normally seen as the moral responsibilities of these actors. This framework is used to analyze, based on four empirical situations, why the implementation of a performance measurement system has not been as effective as expected. It was concluded that, in these (...) four cases, unethical behavior (i.e. deviations from the ethical behaviors identified in the framework) provided, at least to some extent, an explanation for the lower than expected effectiveness of the performance measurement procedures. At the end of the paper we present an agenda for further research through which the framework could be further developed and systematically applied to a broader set of cases. (shrink)

The aim of this article is to provide a preliminary ethical evaluation of the effect of telesurgery on patient care. In order to accomplish this task we give a broad description of the state of the art in telesurgery and analyse it using Joan Tronto’s articulation of care as a structured process. This structure illuminates the significance of the patient-physician relationship as the buttress for establishing and preserving practices of care in the healthcare context, with the ultimate goal of safeguarding (...) patient dignity. The process of care combined with the moral aim of medicine—to fulfil the good of the patient—provides the ethical foundation for assessing telesurgery. By exploring various telesurgical scenarios we may assess its potential role in augmenting or diminishing patient care within the frame of the patient-physician relationship. The significance of conducting this evaluation lies in the fact that the practice of telesurgery may very shortly become routine and an evaluation has not yet been attempted. (shrink)

In this article, we sketch a new approach to law and ethics. The traditional paradigm, exemplified in the debate on liberal moralism, becomes increasingly inadequate. Its basic assumptions are that there are clear moral norms of positive or critical morality, and that making statutory norms is an effective method to have citizens conform to those norms. However, for many ethical issues that are on the legislative agenda, e.g. with respect to bioethics and anti-discrimination law, the moral norms are controversial, vague (...) or still evolving. Moreover, law proves not to be a very effective instrument. Therefore, we need a new paradigm, both for descriptive and for normative analysis. This interactive paradigm, as a normative position, can be summarised in two theses. The process of legislation on ethical issues should be structured as a process of interaction between the legislature and society or relevant sectors of society, so that the development of new moral norms and the development of new legal norms may reinforce each other. And legislation on ethical issues should be designed in such a way that it is an effective form of communication which, moreover, facilitates an ongoing moral debate and an ongoing reflection on such issues, because this is the best method to ensure that the practice remains oriented to the ideals and values the law tries to realise. (shrink)

Two decades of research on euthanasia in the Netherlands have resulted into clear insights in the frequency and characteristics of euthanasia and other medical end-of-life decisions in the Netherlands. These empirical studies have contributed to the quality of the public debate, and to the regulating and public control of euthanasia and physician-assisted suicide. No slippery slope seems to have occurred. Physicians seem to adhere to the criteria for due care in the large majority of cases. Further, it has been shown (...) that the majority of physicians think that the euthanasia Act has improved their legal certainty and contributes to the carefulness of life-terminating acts. In 2005, eighty percent of the euthanasia cases were reported to the review committees. Thus, the transparency envisaged by the Act still does not extend to all cases. Unreported cases almost all involve the use of opioids, and are not considered to be euthanasia by physicians. More education and debate is needed to disentangle in these situations which acts should be regarded as euthanasia and which should not. Medical end-of-life decision-making is a crucial part of end-of-life care. It should therefore be given continuous attention in health care policy and medical training. Systematic periodic research is crucial for enhancing our understanding of end-of-life care in modern medicine, in which the pursuit of a good quality of dying is nowadays widely recognized as an important goal, in addition to the traditional goals such as curing diseases and prolonging life. (shrink)

A hippocampal patient is described who shows preserved item recognition and simple recognition-based recollection but impaired recall and associative recognition. These data and other evidence suggest that contrary to Aggleton & Brown's target article, Papez circuit damage impairs only complex item-item-context recollection. A patient with perirhinal cortex damage and a delayed global memory deficit, apparently inconsistent with A&B's framework, is also described.

Patient competence, defined as the ability to reason, appreciate, understand, and express a choice is rarely discussed in patients with obsessive compulsive disorder, and coercive measures are seldom used. Nevertheless, a psychiatrist of psychologist may doubt whether OCD patients who refuse treatment understand their disease and the consequences of not being treated, which could result in tension between respecting the patient’s autonomy and beneficence. The purpose of this article is to develop a notion of competence that is grounded in clinical (...) practice and corresponds with the experiences of patients with obsessions and/or compulsions. We present a naturalistic case study giving both the patient’s and the therapist’s perspective based on in-depth interviews and a narrative analysis. The case study shows that competence is not merely an assessment by a therapist, but also a co-constructed reality shaped by the experiences and stories of patient and therapist. The patient, a medical student, initially told her story in a restitution narrative, focusing on cognitive rationality. Reconstructing the history of her disease, her story changed into a quest narrative where there was room for emotions, values and moral learning. This fitted well with the therapist’s approach, who used motivational interventions with a view to appealing to the patient’s responsibility to deal with her condition. We conclude that in practice both the patient and therapist used a quest narrative, approaching competence as the potential for practical reasoning to incorporate values and emotions. (shrink)

The fracking debate is a product of the tension between the environmental degradation it may cause, on the one hand, and on the other the greater energy demands of a rapidly increasing South African population with expectations of an ever-increasing standard of living. Shale gas fracking in the Karoo of South Africa promises to make vast reserves of oil and gas available to help meet a significant percentage of the country’s energy needs for many years to come. This will aid (...) development and contribute to raising the standard of living of many. This article seeks to apprise the South African faith communities of the technology and risks involved. Christian theological guidelines are presented by which its benefits and dangers may be interrogated so that the community may be able come to an informed decision as to whether or not to support fracking. (shrink)

An important and supposedly impactful form of clinical ethics support is moral case deliberation. Empirical evidence, however, is limited with regard to its actual impact. With this literature review, we aim to investigate the empirical evidence of MCD, thereby a) informing the practice, and b) providing a focus for further research on and development of MCD in healthcare settings. A systematic literature search was conducted in the electronic databases PubMed, CINAHL and Web of Science. Both the data collection and the (...) qualitative data analysis followed a stepwise approach, including continuous peer review and careful documentation of our decisions. The qualitative analysis was supported by ATLAS.ti. Based on a qualitative analysis of 25 empirical papers, we identified four clusters of themes: 1) facilitators and barriers in the preparation and context of MCD, i.e., a safe and open atmosphere created by a facilitator, a concrete case, commitment of participants, a focus on the moral dimension, and a supportive organization; 2) changes that are brought about on a personal and inter-professional level, with regard to professional’s feelings of relief, relatedness and confidence; understanding of the perspectives of colleagues, one’s own perspective and the moral issue at stake; and awareness of the moral dimension of one’s work and awareness of the importance of reflection; 3) changes that are brought about in caring for patients and families; and 4) changes that are brought about on an organizational level. This review shows that MCD brings about changes in practice, mostly for the professional in inter-professional interactions. Most reported changes are considered positive, although challenges, frustrations and absence of change were also reported. Empirical evidence of a concrete impact on the quality of patient care is limited and is mostly based on self-reports. With patient-focused and methodologically sound qualitative research, the practice and the value of MCD in healthcare settings can be better understood, thus making a stronger case for this kind of ethics support. (shrink)