The clinical ethics literature is striking for the absence of an important genre of scholarship that is common to the literature of clinical medicine: systematic reviews. As a consequence, the field of clinical ethics lacks the internal, corrective effect of review articles that are designed to reduce potential bias. This article inaugurates a new section of the annual "Clinical Ethics" issue of the Journal of Medicine and Philosophy on systematic reviews. Using recently articulated standards for argument-based normative ethics, we provide (...) a systematic review of the literature on concealed medication for the management of psychiatric disorders. Four steps are completed: identify a focused question; conduct a literature search using key terms relevant to the focused question; assess the adequacy of the argument-based methods of the papers identified; and identify conclusions drawn in each paper and whether they apply to the focused question. We identified seven papers and provide an assessment of them. While none of the papers fully meet the standards of argument-based ethics, they did provide rationales for the use of concealed medications, with the important requirement such a practice be accountable in explicit organizational policy to prevent abuse of patients with mental illness or dementia. (shrink)

Incivility among physicians, between physicians and learners, and between physicians and nurses or other healthcare professionals has become commonplace. If allowed to continue unchecked by academic leaders and medical educators, incivility can cause personal psychological injury and seriously damage organisational culture. As such, incivility is a potent threat to professionalism. This paper uniquely draws on the history of professional ethics in medicine to provide a historically based, philosophical account of the professional virtue of civility. We use a two-step method of (...) ethical reasoning, namely ethical analysis informed by pertinent prior work, followed by identifying the implications of clearly articulated ethical concepts, to meet these goals. The professional virtue of civility and the related concept of professional etiquette was first described by the English physician-ethicist Thomas Percival (1740–1804). Based on a historically informed philosophical account, we propose that the professional virtue of civility has cognitive, affective, behavioural and social components based on a commitment to excellence in scientific and clinical reasoning. Its practice prevents a dysfunctional organisational culture of incivility and sustains a civility-based organisational culture of professionalism. Medical educators and academic leaders are in a pivotal and powerful position to role model, promote and inculcate the professional virtue of civility as essential to an organisational culture of professionalism. Academic leaders should hold medical educators accountable for discharge of this indispensable professional responsibility. (shrink)

The best things in my Ufe have come to me by accident and this book results from one such accident: my having the opportunity, out of the blue, to go to work as H. Tristram Engelhardt, Jr. 's, research assistant at the Institute for the Medical Humanities in the University of Texas Medi cal Branch at Galveston, Texas, in 1974, on the recommendation of our teacher at the University of Texas at Austin, Irwin C. Lieb. During that summer Tris "lent" (...) me to Chester Bums, who has done important schol arly work over the years on the history of medical ethics. I was just finding out what bioethics was and Chester sent me to the rare book room of the Medical Branch Library to do some work on something called "medical deontology. " I discovered that this new field of bioethics had a history. This string of accidents continued, in 1975, when Warren Reich (who in 1979 made the excellent decisions to hire me to the faculty in bioethics at the Georgetown University School of Medicine and to persuade Andre Hellegers to appoint me to the Kennedy Institute of Ethics) took Tris Engelhardt's word for it that I could write on the history of modem medical ethics for Warren's major new project, the Encyclopedia of Bioethics. Warren then asked me to write on eighteenth-century British medical ethics. (shrink)

Research to improve the health of pregnant and fetal patients presents ethical challenges to clinical investigators, institutional review boards, funding agencies, and data safety and monitoring boards. The Common Rule sets out requirements that such research must satisfy but no ethical framework to guide their application. We provide such an ethical framework, based on the ethical concept of the fetus as a patient. We offer criteria for innovation and for Phase I and II and then for Phase III clinical trials (...) to improve the health of pregnant patients and of fetal patients and also criteria to responsibly manage the transition from investigation to clinical practice. Basing ethical criteria for research involving pregnant women on the ethical concept of the fetus as a patient insulates the proposed ethical framework and therefore research on pregnant women from the divisive and politicized concepts and discourses of personhood, fetal rights, and unborn child. (shrink)

Despite its prominence in the abortion debate and in public policy, the discourse of 'unborn patient' has not been subjected to critical scrutiny. We provide a critical analysis in three steps. First, we distinguish between the descriptive and normative meanings of 'unborn child.' There is a long history of the descriptive use of 'unborn child.' Second, we argue that the concept of an unborn child has normative content but that this content does not do the work that opponents of abortion (...) want it to do, namely, to establish the independent moral status of fetuses and their rights, the right to life in particular. Third, we argue that the normative content of 'unborn child' should be dependent moral status, not independent moral status. We conclude that the ethical concept of the fetus as a patient should replace the discourse of “unborn child” when that phrase is used normatively. (shrink)

Volume 20, Issue 7, July 2020, Page 9-12.

Bioethics has a founding story in which medical paternalism, the interference with the autonomy of patients for their own clinical benefit, was an accepted ethical norm in the history of Western medical ethics and was widespread in clinical practice until bioethics changed the ethical norms and practice of medicine. In this paper I show that the founding story of bioethics misreads major texts in the history of Western medical ethics. I also show that a major source for empirical claims about (...) the widespread practice of medical paternalism has been misread. I then show that that bioethics based on its founding story deprofessionalizes medical ethics. The result leaves the sick exposed to the predatory power of medical practitioners and healthcare organizations with only their autonomy-based rights to non-interference, expressed in contracts, to protect them. The sick are stripped of the protection afforded by a professional, fiduciary relationship of physicians to their patients. Bioethics based on its founding story reverts to the older model of a contractual relationship between the sick and medical practitioners not worthy of intellectual or moral trust (because such trust cannot be generated by what I call ‘deprofessionalizing bioethics’). On closer examination, bioethics based on its founding story, ironically, eliminates paternalism as a moral category in bioethics, thus causing bioethics to collapse on itself because it denies one of the necessary conditions for medical paternalism. Bioethics based on its founding story should be abandoned. (shrink)

Research to improve the health of pregnant and fetal patients presents ethical challenges to clinical investigators, institutional review boards, funding agencies, and data safety and monitoring boards. The Common Rule sets out requirements that such research must satisfy but no ethical framework to guide their application. We provide such an ethical framework, based on the ethical concept of the fetus as a patient. We offer criteria for innovation and for Phase I and II and then for Phase III clinical trials (...) to improve the health of pregnant patients and of fetal patients and also criteria to responsibly manage the transition from investigation to clinical practice. Basing ethical criteria for research involving pregnant women on the ethical concept of the fetus as a patient insulates the proposed ethical framework and therefore research on pregnant women from the divisive and politicized concepts and discourses of personhood, fetal rights, and unborn child. (shrink)

Albert Jonsen in The Birth of Bioethics notes that his career in bioethics began with a phone call to him from soon-to-be colleagues at the University of California at San Francisco Medical Center. Bioethics didn't begin with a bang but as an accident in the root sense—something that happened, not by necessity, but rather by chance. Indeed, the opening chapters of Jonsen's book chronicle a series of accidents that helped to create the field of bioethics. Principal among these was the (...) fact that physicians and biomedical scientists who became puzzled about the moral dimensions of their work and began to think about these puzzles sought help in doing so from moral theologians and philosophers. These physicians and scientists, for the most part, were university people. They thought broadly, not just deeply, about their work, but they just as well could have defined themselves by their academic discipline and departments and not reached beyond these familiar and comfortable intellectual confines to the “culture” of the humanities disciplines and departments. The theologians and philosophers whom these physicians and scientists sought out were also university people who also happened to have generous views of the intellectual life in their disciplines—atypical of the time, especially in philosophy. If C. P. Snow had been altogether right and if ungenerous self-understanding of their work by physicians, scientists, philosophers, and theologians had prevailed, bioethics might not have happened at all. (shrink)

Volume 20, Issue 3, March 2020, Page 65-68.

In his Disrupted Dialogue: Medical Ethics and the Collapse of Physician-Humanist Communication Robert Veatch presents a scholarly tour de force of eighteenth- and nineteenth-century Anglophone medical ethics to demonstrate how the easy communication between physicians and humanists in the Scottish Enlightenment progressively dissipated as medicine became detached from humanistic disciplines. In this paper I offer two comments—that the discourse of medical ethics in the Scottish Enlightenment was a discourse of Baconian moral science and that nineteenth-century medical ethics in the United (...) States became detached from that discourse. The result was that a principal resource for physicians at the birth of bioethics, the American Medical Association’s Principles of Medicine Ethics of 1957, did not equip physicians with the conceptual tools they needed to formulate and address the ethical challenges that became the agenda of bioethics. The paper opens with a brief portrait of Robert Veatch, the author’s connections to him, and his little-known role as an impresario of the classical music of the Blue Ridge and Appalachia. (shrink)

This volume reprints in a scholar's edition the first English-language texts on bioethics, John Gregory's (1724-1773) Observations on the Duties and Offices of a Physician and on the Method of Prosecuting Enquiries in Philosophy (London, 1770) and Lectures on the Duties and Qualifications of a Physician (London, 1772). Five previously unpublished manuscripts of Gregory's lectures are also included. An introduction places Gregory's medical ethics and philosophy of medicine in their eighteenth-century contexts of Scottish Enlightenment history and culture, Baconian science and (...) philosophy of medicine, medical practice, the feminine and feminist philosophy of the Bluestocking Circle, and moral sense philosophy, particularly David Hume's concept of sympathy, and provides a bibliography of primary and secondary sources as an aid to teaching and future scholarship. The book's index provides access to Gregory's texts, by using both historical terms and current terminology of bioethics. A volume in the subseries Classics of Medical Ethics. (shrink)

Rosamond Rhodes makes a persuasive case for the view that medical ethics does not derive from common morality.1 Rhodes identifies the challenge that immediately arises and its corollary: Whence the origin of medical ethics? And, should we understand medical ethics as autonomous? From the perspective of professional ethics in medicine, the first question can now be restated: Whence the origin of the ethical concept of medicine as a profession, the basis of the ethical obligations of physicians in patient care, research, (...) medical education, and in advocacy and healthcare policy? The history of Western philosophy offers us two pathways to address this question. The first is the quest for certainty,2 a quest fulfilled by using methods designed to discover concepts that are independent of human thought and judgement and thus intellectually and morally authoritative for everyone. Such concepts are timeless and therefore transcultural, transreligious and transnational. Examples include Plato’s Forms,3 PF Stawson’s ‘our conceptual structure’,4 Edmund Pellegrino’s ‘fact of illness’ and the ‘act of profession’ in response to the vulnerability that illness creates,5 and common morality.6 Thought experiments, using what Rhodes characterises as ‘the hypethetico-deductive method’,1 aim to discover timeless concepts. Discovering timeless concepts must address their ontological and epistemological status. Plato’s ontology of Forms,2 for example, is not clear, as …. (shrink)

Book reviewed in this article: Ethics in Obstetrics and Gynecology. By Laurence B. McCullough and Frank A. Chervenak.

The concept of medicine as a profession in the English-language literature of medical ethics is of recent vintage, invented by the Scottish physician and medical ethicist, John Gregory (1724-1773). Gregory wrote the first secular, philosophical, clinical, and feminine medical ethics and bioethics in the English language and did so on the basis of Hume's principle of sympathy. This paper provides a brief account of Gregory's invention and the role that Humean sympathy plays in that invention, with reference to key texts (...) in Gregory's work. The paper also considers two interesting and perhaps provocative ways in which Hume can be read through Gregory: first, sympathy as a principle of scientific discovery in Hume's science of man and moral physiology; and sympathy as gendered feminine in Hume's moral philosophy. Hume's principle of sympathy is at the core of Gregory's medical ethics and the histories of Western medical ethics and bioethics pivot on Gregory - and, therefore, on Hume - as it does on few other figures. (shrink)

Despite its prominence in the abortion debate and in public policy, the discourse of ‘unborn patient’ has not been subjected to critical scrutiny. We provide a critical analysis in three steps. First, we distinguish between the descriptive and normative meanings of ‘unborn child.’ There is a long history of the descriptive use of ‘unborn child.’ Second, we argue that the concept of an unborn child has normative content but that this content does not do the work that opponents of abortion (...) want it to do, namely, to establish the independent moral status of fetuses and their rights, the right to life in particular. Third, we argue that the normative content of ‘unborn child’ should be dependent moral status, not independent moral status. We conclude that the ethical concept of the fetus as a patient should replace the discourse of “unborn child” when that phrase is used normatively. (shrink)

Leibniz's earliest philosophy and its importance for his mature philosophy have not been examined in detail, particularly in the level of detail that one can achieve by placing Leibniz's philosophy in the context of the sources for two of the most basic concerns of his philosophical career: his metaphysics of individuals and the principle oftheir individuation. In this book I provide for the first time a detailed examination of these two Leibnizian themes and trace its implications for how we should (...) interpret other major Leibnizian themes and for how we should read Leibniz and other philosophers of the sixteenth and later centuries as 'modem' philosophers. Leibniz began his philosophical career more than 300 years ago, a fact that shapes fundamentally my attempt in the pages that follow to come to terms now with the texts that he left us. Leibniz's did not do philosophy in a way wholly congenial to twentieth century philosophical methodologies, especially those that have enjoyed some prominence in recent Anglo-American philosophy. Moreover, as we shall see, Leibniz is not a modem philosopher, when 'modem' is understood to mean making a sharp break with medieval philosophy. Indeed, I shall argue, scholars should discard such terms as 'modem' from historical philosophical scholarship, so that old texts can be allowed to remain old - to stand on their own in and from times now long past. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Laying Medicine Open: Understanding Major Turning Points in the History of Medical EthicsLaurence B. McCullough (bio)AbstractAt different times during its history medicine has been laid open to accountability for its scientific and moral quality. This phenomenon of laying medicine open has sometimes resulted in major turning points in the history medical ethics. In this paper, I examine two examples of when the laying open of medicine has generated (...) such turning points: eighteenth-century British medicine and late twentieth-century American medicine. In the eighteenth century, the Scottish physician-philosopher, John Gregory (1724–1773), concerned with the unscientific, entrepreneurial, self-interested nature of then current medical practice, laid medicine open to accountability using the tools of ethics and philosophy of medicine. In the process, Gregory wrote the first professional ethics of medicine in the English-language literature, based on the physician’s fiduciary responsibility to the patient. In the late twentieth century, the managed practice of medicine has laid medicine open to accountability for its scientific quality and economic cost. This current laying open of medicine creates the challenge of developing medical ethics and bioethics for population-based medical science and practice.Reading the Histories of Medicine, Bioethics, and Medical EthicsThere are many ways in which to read the history of medi-cine and therefore of medical ethics and bioethics. For example, the history of medicine can be usefully understood in terms of successive advances or revolutions in biomedical science and its clinical applications, with medical ethics understood as a moral response to scientific and technological change. On this reading, which has been common in the history of bioethics for the past three decades, moral response is required to address scientific and technological changes that are unprecedented and therefore threaten to outstrip society’s moral capacities [End Page 7] to understand and manage those changes well. Much recent work on the ethical, legal, and social issues raised by the genome project appeals to this reading. The history of medicine can also be read in social terms, with medicine understood as a major social institution shaped by various factors, not limited to science. In this perspective, medicine and society are understood in terms of a complex and dynamic synergy. Bioethics and medical ethics become part of this synergy and are to be explained—perhaps even explained away—by social historical factors. There are, of course, other ways to read the history of medicine and therefore of bio-ethics and medical ethics—e.g., in terms of key figures and movements that are thought to have shaped developments in crucial ways.I want to suggest another way to read these histories, namely, the successive laying open of medicine to accountability that sometimes results in key turning points in the development of medical ethics and bioethics. On this reading, ethics is understood as an intellectual and practical discipline that makes medicine as a social institution and its practitioners, physicians, morally accountable for their clinical judgment, decision making, and behavior. This differs from Robert Veatch’s (1981) reading of the history of medical ethics either as particular—informed by intellectual, moral, and experiential resources thought to be available only to physicians—or universal—informed by intellectual, moral, and experiential resources generally available in the culture (present and past). Veatch sees medical ethics as open when it is universal and closed, and unacceptable, when it is particular. I read the history of medical ethics as always universal and medicine as a social institution and practice as sometimes closed—i.e, not accountable for its scientific and moral integrity—and sometimes as open, accountable for such integrity. When medicine is “laid open,” medical ethics itself is sometimes transformed. The same may well be the case for the other health care professions. The histories of medical ethics and bioethics, therefore, can be usefully read as responses to the laying open of medicine and the health care professions generally at various times in their histories. In what follows, I examine two important examples of laying medicine open that create key turning points in the history of medical ethics—Scottish medicine from the eighteenth century and American medicine from the end of the twentieth century.The... (shrink)

(2001). The History of Medical Ethics Is Crucial for a Critical Perspective in the Continuing Development of Ethics Consultation. The American Journal of Bioethics: Vol. 1, No. 4, pp. 55-57.

In diesem Aufsatz zeige ich, wie Leibniz' spätere Philosophie auf seine frühen Arbeiten und auf die spätscholastische Philosophie, insbesondere den Nominalismus von Suarez, zurückgreift. Zunächst behaupte ich, daß Leibniz Suarez' Ontologie der Relationen ebenso wie seine Auffassung der Begriffe, des Besonderen und des Allgemeinen übernommen hat. Ich verwende die Ergebnisse dieser Untersuchung, um einige Hauptthemen der Leibnizschen Philosophie (die Theorie der Monaden und ihrer individuellen Begriffe, die Kategorienlehre, die Wahrheitstheorie, die unendliche Analyse und das principium indiscernibilium) zu erklären. Dieser Aufsatz (...) soll die traditionelle Prägung von einem großen Teil des Leibnizschen Denkens aufzeigen und die Frage neu stellen: In welchem Sinne ist Leibniz ein Philosoph der modernen Tradition? (shrink)

THIS PAPER IS A COMMENTARY ON LUDWIK FLECK'S ESSAY ON THE CONNECTION BETWEEN WHAT HE CALLS "THOUGHT-STYLES" AND SCIENTIFIC AND MEDICAL CONCEPTS. THE IDEA OF A "THOUGHT-STYLE" APPLIED TO CONCEPTS OF DISEASE IS THAT THEY ARE NOT ONLY VALUE-LADEN IN THE SENSE OF INCLUDING NORMATIVE DIMENSIONS. THEY ALSO EMBRACE BROAD SOCIAL FACTORS, AS WELL. I ARGUE THAT THOUGHT-STYLES SHOULD BE UNDERSTOOD TO BE "OPEN-TEXTURED," ADMITTING A PLURALITY OF VALUE CONSIDERATIONS TO CONCEPTS OF DISEASE.

Managed care employs two business tools of managed practice that raise important ethical issues: paying physicians in ways that impose conflicts of interest on them; and regulating physicians' clinical judgment, decision making, and behavior. The literature on the clinical ethics of managed care has begun to develop rapidly in the past several years. Professional organizations of physicians have made important contributions to this literature. The statements on ethical issues in managed care of four such organizations are considered here, the American (...) Medical Association, the American College of Physicians, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics. Three themes common to these statements are identified and critically assessed: the primacy of meeting the medical needs of each individual patient; disclosure of conflicts of interest in how physicians are paid; and opposition to gag orders. The paper concludes with an argument for a basic concept in the clinical ethics of managed care: physicians and institutions as economically disciplined moral co-fiduciaries of populations of patients. (shrink)

Nancy Jecker (2013) mounts a sustained and formidable critique of Norman Daniels's prudential lifespan account (PLA) as a reliable basis for justice between age groups in the responsible allocation...

Some problems that arise in the account given by Thomasma and Pellegrino [6] of the foundations of medical ethics in a philosophy of medicine are addressed, in particular questions of a conceptual character about treating therelatum of medicine as health. Which concept of health is appropriate and which will bear the burden of the position thomasma and Pellegrino advance? It is argued that the proper relationship of medicine is one between a healer and developing embodied minds. As a consequence, the (...) project of providing a univocal account of the nature of medicine fails. Instead, pluralism infects philosophy and medicine, resulting in different philosophies of medicine. From these philosophies of medicine will follow not a single medical ethics but a variety. (shrink)

Taking the critical turn is one of the main tools of the humanities and inculcates an intellectual discipline that prevents ossification of thinking about issues and of organizational policies in clinical ethics. The articles in this "Clinical Ethics" number of the Journal take the critical turn with respect to cherished ways of thinking in Western clinical ethics, life extension, the clinical determination of death, physicians' duty to treat even at personal risk, clinical ethics at the interface of research ethics, and (...) the pertinence of the Hippocratic Oath to clinical ethics. These articles challenge clinical ethicists to inculcate the intellectual discipline of the critical turn into everyday practice and continuous quality enhancement of clinical ethics. (shrink)

The pluralism of methodologies and severe time constraints pose important challenges to pedagogy in clinical ethics. We designed a step-by-step student handbook to operate within such constraints and to respect the methodological pluralism of bioethics and clinical ethics. The handbook comprises six steps: Step 1: What are the facts of the case?; Step 2: What are your obligations to your patient?; Step 3: What are your obligations to third parties to your relationship with the patient?; Step 4: Do your obligations (...) converge or conflict?; Step 5: What is the strongest objection that could be made to the identification of convergence in step 4 or the arguments in step 4? How can this objection be effectively countered?; and Step 6: How could the ethical conflict, or perceived ethical conflict, have been prevented? (shrink)

Moral concerns about the authority, power, and trustworthiness of physicians have become important topics in clinical ethics during the past three decades. These concerns have come to greater prominence with the increasing involvement of large-scale private institutions in the organization and delivery of medical services, especially managed care organizations, and with the increasing involvement of government in the payment for and organization and delivery of medical services. When physicians act as the agents of large institutions or governments, the power of (...) physicians over their patients increases. The purposes of this article are (1) to reflect briefly on the historical origins of the moral problem of physicians' power in medicine, and (2) to introduce the articles in the 1999 annual number of the Journal of Medicine and Philosophy on topics in clinical ethics. (shrink)

The nature and limits of the physician's professional responsibilities constitute core topics in clinical ethics. These responsibilities originate in the physician's professional role, which was first examined in the modern English-language literature of medical ethics by two eighteenth-century British physician-ethicists, John Gregory and Thomas Percival. The papers in this annual clinical ethics number of the Journal explore the physician's professional responsibilities in the areas of surgical ethics, matters of conscience, and managed care.

In lieu of an abstract, here is a brief excerpt of the content:Bioethics in the Twenty-First Century: Why We Should Pay Attention to Eighteenth-Century Medical EthicsLaurence B. McCullough (bio)Those of us who work in the field of bioethics tend to think that, because the word “bioethics” is new, so too the field is new in all respects, but we are not the first to do bioethics. John Gregory (1724–1773) did bioethics just as we do it, at least two centuries (...) before we thought to do it (Gregory 1772). He deployed philosophical methods as sophisticated as our own. Indeed, Gregory took up the very best moral philosophy available to thinkers of the Scottish Enlightenment, namely, David Hume’s moral philosophy and its core concept of sympathy. Gregory also responded in a conceptually powerful and clinically applicable way to the problems of his time, just as we do. I want here to outline Gregory’s accomplishment and to identify some aspects of its importance for bioethics in the twenty-first century.Gregory’s “Problem List”Gregory wrote his medical ethics as a response to the then current state of medicine in Britain. We now follow Gregory in our writing of bioethics and clinical ethics in response to the problems of our time. A great deal that we now take for granted did not then exist. 1There was not, as there is now, any uniform pathway into medicine. Nor did there exist universal licensure. The Royal Colleges did attempt to assert, but failed to achieve, monopoly control of medical practice. The concepts of health and disease were themselves contested and therefore competed for their success in the market place. There was a marked oversupply of practitioners who competed fiercely—very fiercely indeed—in the medical market place for their concepts of health and disease, their treatments, and therefore their livelihoods. Patients had their own concepts of health and disease, engaged in “self-physicking” or self-care, and often traded physician’s prescriptions.Medicine exhibited little scientific discipline in its accounts of disease and in determining the efficacy of treatments, a fact that Gregory (1743) laments as a [End Page 329] medical student. There was no marked improvement when he began to give his medical ethics lectures nearly a quarter of a century later. Treatments failed as often, perhaps more often, than they succeeded in benefiting patients. The sick usually sought out the help of a physician after trying self-physicking.Physicians, Gregory taught, could not hope to control human biology, though they could aim to manage its processes well. When nature underresponds to disease the physician should assist her processes; when nature overresponds, the physician should tamp down nature’s responses, to lessen their “violence”—in both cases always attentive to the limits of medicine’s capacities in treating disease.Physicians attended the well-to-do sick at home, and the sick person summoned and dismissed physicians, surgeons, or apothecaries at will. A physician therefore might find himself—no women had yet been admitted to the ranks of university-trained physicians—summoned before, after, or simultaneously with a competitor, with his concepts and diagnosis and treatment put to the acid test. In this setting, there existed only a patient-physician relationship, not a physician-patient relationship.Physicians left off the care of dying patients, a practice that was made a matter of duty by Friederich Hoffmann (1749). One would suffer punishing economic consequences if one had a high mortality rate. Better, then, to label the patient incurable, withdraw, and turn matters over to clergy. Gregory attacks this practice as intellectual fraud and calls for the physician to continue to attend the dying. Indeed, he says, “It is as much the business of a physician to alleviate pain, and to smooth the avenues of death, when unavoidable, as to cure diseases” (Gregory 1772, p. 35). He does not explicitly address what we now call physician-assisted suicide; neither does he condemn it, and he is quick to condemn some things—e.g., sexual abuse of female patients or “sporting” with patients in the Royal Infirmary by using experiments as the first line of treatment.The Royal Infirmary was established to care for the deserving, working poor, who received free care... (shrink)

In this commentary on Carse and Rushton’s call for reorientation of moral distress, we state agreement with the authors that the discourse of moral distress should refocus on the moral components of integrity. We then explain how our philosophical taxonomy of moral distress, mentioned by the authors, appeals to moral integrity. In this process, we clarify our taxonomy’s appeal to Aristotle’s concept of akrasia. We conclude by offering support of Carse and Rushton’s challenge to organizations to strengthen moral integrity by (...) fostering resilience. (shrink)

American Academy of Pediatrics (AAP) and American College of Medical Genetics (ACMG) recently provided two recommendations about predictive genetic testing of children. The Clinical Sequencing Exploratory Research Consortium's Pediatrics Working Group compared these recommendations, focusing on operational and ethical issues specific to decision making for children. Content analysis of the statements addresses two issues: (1) how these recommendations characterize and analyze locus of decision making, as well as the risks and benefits of testing, and (2) whether the guidelines conflict or (...) come to different but compatible conclusions because they consider different testing scenarios. These statements differ in ethically significant ways. AAP/ACMG analyzes risks and benefits using best interests of the child and recommends that, absent ameliorative interventions available during childhood, clinicians should generally decline to order testing. Parents authorize focused tests. ACMG analyzes risks and benefits using the interests of the child and other family members and recommends that sequencing results be examined for additional variants that can lead to ameliorative interventions, regardless of age, which laboratories should report to clinicians who should contextualize the results. Parents must accept additional analysis. The ethical arguments in these statements appear to be in tension with each other. (shrink)

In our ‘The Professional Virtue of Civility and the Responsibilities of Medical Educators and Academic Leaders’,1 we provided an historically based conceptual account of the professional virtue of civility and the role of leaders of academic health centres in creating and sustaining an organisational culture of professionalism that promotes civility among healthcare professionals and between medical educators and learners. We emphasised that any adequate understanding of the virtues, including professional virtues, has cognitive, affective, behavioural and social components. Some of the (...) commentators expand on these components in important ways. Xuhao et al emphasises the importance of role models, especially in the hierarchical context of medical education.2 The hierarchy of faculty in the senior position and junior doctors and other learners below them has characterised medical education for centuries. Xuhao et al rightly call for academic leaders to shape this hierarchy in a morally responsible way, by becoming ‘exemplary role models’.2 Berry, a clinician manager, in critiquing our account, calls for an increased appreciation for the psychological and environmental factors that might explain why uncivil behaviour occurs.3 …. (shrink)

This is the first textbook of surgical ethics. It is a practical, clinically comprehenive, well-organized guide to ethical issues in surgical practice, research, and education written by leading figures in surgery and bioethics. The authors cover the surgeon-patient relationship, the full range of surgical patients, surgical education and research, and surgery and managed care. Their chapters are not abstract discussions of ethical principles; rather, they connect directly with the everyday concerns of practicing surgeons.

Methodological concerns are moving to the top of the bioethics agenda for the next decade. This paper examines some of those concerns: (1) medical ethics as a subset of bioethics versus medical ethics as a subset of professional ethics; (2) a more in-depth examination of some methodological problems in treating medical ethics as professional ethics; (3) the senses in which bioethics constitutes an inquiry into secular undertakings in a pluralistic society; (4) ‘federal ethics’, the emergence to prominence of public commissions (...) and study groups; and (5) the institutional impact of bioethics on the relationship between medical schools and the liberal arts core of their sponsoring universities. Keywords: bioethics, medical ethics, methodology, pluralism, federal ethics CiteULike Connotea Del.icio.us What's this? (shrink)

An orthodoxy has arisen which claims that there is a crisis in the United States health care system such that the system needs to be reformed. This essay challenges that orthodoxy by showing that we do not have a health care system in the United States. We have a non-system of health care, just as we do for virtually all basic social institutions. Challenging the current orthodoxy surfaces two ethical issues that have been ignored: creating a health care system will (...) (a) cause resurgent paternalism and (b) pose a threat to moral pluralism. Keywords: Health care policy, managed care, paternalism, moral pluralism, institutional integrity, total quality management, continuous quality improvement CiteULike Connotea Del.icio.us What's this? (shrink)