Healthcare priority-setting institutions have good reason to want to demonstrate that their decisions are morally justified—and those who contribute to and use the health service have good reason to hope for the same. However, finding a moral basis on which to evaluate healthcare priority-setting is difficult. Substantive approaches are vulnerable to reasonable disagreement about the appropriate grounds for allocating resources, while procedural approaches may be indeterminate and insufficient to ensure a just distribution. In this paper, we set out a complementary, (...) coherence-based approach to the evaluation of healthcare priority-setting. Drawing on Rawls, we argue that an institutional priority-setter’s claim to moral justification can be assessed, in part, based on the extent to which its many normative commitments are mutually supportive and free from dissonance; that is, on the ability to establish narrow reflective equilibrium across the normative content of a priority-setter’s policy and practice. While we do not suggest that the establishment of such equilibrium is sufficient for moral justification, we argue that failure to do so might—like the proverbial canary in the coalmine—act as a generalised warning that something is awry. We offer a theoretical argument in support of this view and briefly outline a practical method for systematically examining coherence across priority-setting policy and practice. (shrink)

This paper takes up the question of the role of philosophical moral theory in our attempts to resolve the ethical problems that arise in health care, with particular reference to the contention that we need theory to be determinative of our choice of actions. Moral theorizing is distinguished from moral theories and the prospects for determinacy from the latter are examined through a consideration of the most promising candidates: utilitarianism, deontology and the procedures involved in reflective equilibrium. It is argued (...) that the current lack of any generally accepted method of solving moral problems, together with the extreme improbability of philosophy achieving a plausibly determinate theory, should encourage us to approach the problems in a spirit of agnosticism regarding the way in which theoretical material might be of relevance. The practical test for both moral theorizing and moral theories is thus not determinacy but the degree to which they increase our understanding of moral problems by serving, as they do in philosophy, as a means of inquiry into their nature. (shrink)

BackgroundViral pandemics present a range of ethical challenges for policy makers, not the least among which are difficult decisions about how to allocate scarce healthcare resources. One important question is whether healthcare workers should receive priority access to a vaccine in the event that an effective vaccine becomes available. This question is especially relevant in the coronavirus pandemic with governments and health authorities currently facing questions of distribution of COVID-19 vaccines.Main textIn this article, we critically evaluate the most common ethical (...) arguments for granting healthcare workers priority access to a vaccine. We review the existing literature on this topic, and analyse both deontological and utilitarian arguments in favour of HCW prioritisation. For illustrative purposes, we focus in particular on the distribution of a COVID-19 vaccine. We also explore some practical complexities attendant on arguments in favour of HCW prioritisation.ConclusionsWe argue that there are deontological and utilitarian cases for prioritising HCWs. Indeed, the widely held view that we should prioritise HCWs represents an example of ethical convergence. Complexities arise, however, when considering who should be included in the category of HCW, and who else should receive priority in addition to HCWs. (shrink)

Empirical studies on people's moral attitudes regarding ethically challenging topics contribute greatly to research in medical ethics. However, it is not always clear in which ways this research adds to medical ethics as a normative discipline. In this article, we aim to provide a systematic account of the different ways in which attitudinal research can be used for normative reflection. In the first part, we discuss whether ethical judgements can be based on empirical work alone and we develop a sceptical (...) position regarding this point, taking into account theoretical, methodological and pragmatic considerations. As empirical data should not be taken as a direct source for normative justification, we then delineate different ways in which attitudes research can be combined with theoretical accounts of normative justification in the second part of the article. Firstly, the combination of attitudes research with normative-ethical theories is analysed with respect to three different aspects: The extent of empirical data which is needed, the question of which kind of data is required and the ways in which the empirical data are processed within the framework of an ethical theory. Secondly, two further functions of attitudes research are displayed which lie outside the traditional focus of ethical theories: the exploratory function of detecting and characterising new ethical problems, and the field of ‘moral pragmatics’. The article concludes with a methodological outlook and suggestions for the concrete practice of attitudinal research in medical ethics. (shrink)

Cornell realism (CR), a prominent meta-ethical position that has emerged since the last decades of the twentieth century, proposes a non-reductionist naturalistic account of moral properties and facts. This paper argues that the best version of CR’s chosen methodology for arriving at justified moral beliefs must be seen as a variant of reflective equilibrium. In comparison to the traditional versions, our proposal offers a ‘social’ reinterpretation of reflective equilibrium in delineating CR’s epistemology. We argue that it satisfactorily accounts for objectivity (...) and calls for the inclusion of the social nature of both moral and scientific inquiries. Emphasising the social dimension of their epistemological account also nudges debates in metaethics into incorporating the much-needed social dimension while dealing with questions of moral beliefs and facts that have been of CR’s concern. (shrink)

Reflective equilibrium has been criticized for various reasons ever since the publication of Rawls’ A Theory of Justice. Recent empirical research into moral decision-making poses new challenges to RE because it questions the reliability of moral intuitions. This research might discredit moral intuitionism in general and RE in particular insofar as it ascribes epistemic value to moral intuitions. These findings suggest, for instance, that moral intuitions vary with cultural background, gender or framing. If it could be shown that all or (...) certain kinds of moral intuitions are unreliable, this would diminish the plausibility of the claim that they provide good reasons to believe in the truth of their content, especially given the growing evidence that professional philosophers are just as biased and susceptible to distorting factors as lay people. In this paper I critically discuss three recent defenses of RE against this unreliable intuitions objection. Two of these defenses argue that the UIO misses its target, because RE does not depend on intuitions, or because the relevant considered judgments in RE are not intuitions. The third defense grants that RE depends on intuitions and that some Rawlsian considered judgments are intuitions. But it argues that the notion of considered judgments can be revised, and that wide reflective equilibrium has the means to adopt the criticism because it can use information about unreliable intuitions and exclude those from further consideration. I argue that the first two defenses do not succeed. The third defense is the most promising one. However, I argue that this defense also fails. In this defense, RE is not a distinctive moral epistemic theory: different versions of RE would be conceivable, all of which are deeply problematic. I conclude with a discussion of the broader philosophical implications of the UIO, specifically whether or not accepting the UIO would warrant skepticism regarding moral knowledge. (shrink)

The increased complexity of health information management sows the seeds of inequalities between health care stakeholders involved in the production and use of health information. Patients may thus be more vulnerable to use of their data without their consent and breaches in confidentiality. Health care providers can also be the victims of a health information system that they do not fully master. Yet, despite its possible drawbacks, the management of health information is indispensable for advancing science, medical care and public (...) health. Therefore, the central question addressed by this paper is how to manage health information ethically? This article argues that Paul Ricœur’s ‘‘little ethics’’, based on his work on hermeneutics and narrative identity, provides a suitable ethical framework to this end. This ethical theory has the merit of helping to harmonise self-esteem and solicitude amongst patients and healthcare providers, and at the same time provides an ethics of justice in public health. A matrix, derived from Ricœur’s ethics, has been developed as a solution to overcoming possible conflicts between privacy interests and the common good in the management of health information. (shrink)

In his 1987 paper “Truth or Consequences,” Dan Brock describes a deep conflict between the goals and virtues of philosophical scholarship and public policymaking: whereas the former is concerned with the search for truth, the latter must primarily be concerned with promoting good consequences. When philosophers are engaged in policymaking, he argues, they must shift their primary goal from truth to consequences—but this has both moral and methodological costs. Brock’s argument exemplifies a pessimistic, but not uncommon, view of the possible (...) shape and nature of applied philosophy. The present paper paints a richer and more optimistic picture. It argues that the difference between theoretical philosophy and applied philosophy is not best understood as a choice between truth and consequences. On the contrary, applied philosophers engage in forms of truth‐seeking that are properly concerned with consequences—including the consequences of philosophical practice itself. (shrink)

Moral Theory and Theorizing in Healthcare Ethics Content Type Journal Article Category Editorial Pages 365-368 DOI 10.1007/s10677-011-9291-x Authors Mike McNamee, College of Human and Health Sciences, Swansea, SA28PP UK Thomas Schramme, Universität Hamburg, Philosophisches Seminar, Von-Melle-Park 6, 20146 Hamburg, Germany Journal Ethical Theory and Moral Practice Online ISSN 1572-8447 Print ISSN 1386-2820 Journal Volume Volume 14 Journal Issue Volume 14, Number 4.

Auch in der Sozialen Arbeit stellt sich die Notwendigkeit, Entscheide ethisch legitimieren zu müssen. Nicht nur können durch ihre Interventionen hohe ethische Güter der betroffenen Person berührt sein, sondern zudem treten nicht selten auch Entscheidungssituationen auf, in denen die anstehende Entscheidung unsicher und umstritten ist. Anhand der erwachsenenschutzrechtlichen Seite der Kindes- und Erwachsenenschutzbehörde in der Schweiz werden wir in diesem Beitrag den Versuch unternehmen, John Rawls’ Überlegungsgleichgewicht in seinen Grundzügen in eine konkrete Praxis zu überführen mit dem Ziel, ethische Leitlinien (...) zur Entscheidungsfindung im Rahmen der KESB zu entwickeln. Dafür sind zunächst ein paar einleitende Bemerkungen zur KESB erforderlich, um ihre Spezifika zu skizzieren. Anschließend erfolgen einige Anmerkungen zu Herausforderungen der Entscheidungsfindung in der Praxis. Danach werden wir unser Modell in seinen Grundzügen umreißen und gesondert auf den Prozess der Deliberation eingehen, die in einem kollektiven Überlegungsgleichgewicht mündet. (shrink)

Is it morally justifiable to force non-consenting pregnant women to submit to caesarean surgery to save their fetus in distress? Even though proponents and opponents largely agree on the interests at stake, such as the health and life of the fetus and the respect for bodily integrity and autonomy of pregnant women, they disagree on which moral weight to attach to these interests. This is why disagreements about the justifiability of forced caesareans tend to be pervasive and intractable. To sidestep (...) this deadlock, we will focus on conditions that give rise to the ‘caesarean dilemma’ in the first place, namely the conflict between inherent norms and values medical professionals are committed to by virtue of being a medical professional. Using the reflective equilibrium, we will test the opponents’ and proponents’ considered judgments about forced caesareans against the norms and values they—as medical professionals—are committed to and determine whether they are coherent. Subsequently we will identify the proponents’ incoherencies between the considered judgments and norms and values they are committed to and conclude that as long as these incoherencies are in place, forced caesareans are morally impermissible. (shrink)

A 90-year-old man is diagnosed with early dementia. There are concerns about whether he is still fit to drive his car safely, but he is determined to continue driving. In this case, the clinician finds that this decision on fitness to drive is essentially evaluative and normative. Given the conflict of interests involved, how should the clinician attempt to manage this challenging ethical dilemma? This increasingly common clinical ethics scenario warrants further attention. After presenting the case, this analysis will consider (...) the relevant issues in three dimensions: an ethical dilemma, a clinician–patient interaction, and a broader context. This analysis provides a potential framework for clinicians making decisions on fitness to drive in early dementia. (shrink)

ZusammenfassungDer vorliegende Beitrag erläutert anhand ausgewählter Beispiele das Potential von Dystopien für die Bioethik. Hierfür werden bestehende Ansätze narrativer Ethik kritisch rekonstruiert und erweitert. Mittels eines Theorieangebots aus der Literaturwissenschaft wird vorgeschlagen, moralische Überzeugungen, die Dystopien motivieren, in kohärentistische Reflexions- und Begründungsverfahren einzubeziehen. Weiterhin wird systematisch herausgearbeitet, welches Potential Dystopien durch sozio-kulturell dichte Szenarien, einen zeitgeschichtlichen Kontext und durch eine Sensibilisierung für die moralische Relevanz der Sprache für die bioethische Forschung bieten. Die dargestellten methodologischen Überlegungen bieten zum einen praktische Bezugspunkte (...) für didaktische Ansätze und zum anderen für die öffentliche Deliberation. Die Analyse zeigt jedoch auch, dass Dystopien jenseits einer Illustration oder Warnung eigene moralische Positionen zur Diskussion stellen. (shrink)

Ever since the introduction of reflective equilibrium in ethics, it has been argued that reflective equilibrium either leads to moral relativism, or that it turns out to be a form of intuitionism in disguise. Despite these criticisms, reflective equilibrium remains the most dominant method of moral justification in ethics. In this paper, I therefore critically examine the most recent attempts to defend the method of reflective equilibrium against these objections. Defenders of reflective equilibrium typically respond to the objections by saying (...) that either reflective equilibrium can in fact safeguard moral objectivity or alternatively, even if it cannot, that there simply are no reasonable alternatives. In this paper, I take issue with both responses. First, I argue that given the non-foundationalist aspirations of reflective equilibrium, moral objectivity cannot be maintained. Second, I argue that reflective equilibrium is not the only game in town once intuitionism has been discarded. I argue that given their own normative ambitions, combined with their rejection of intuitionism, proponents of reflective equilibrium have reason to take alternative methods of moral justification, and more specifically transcendental arguments, more seriously than they have done so far. I end by sketching the outlines of what this alternative methodology might look like. (shrink)

O presente artigo discute as diferentes aplicações do método de justificação conhecido como 'equilíbrio reflexivo' na bioética. Na primeira parte, reconstrói-se a caracterização do método feita por Rawls em "A Theory of Justice", a distinção posterior entre "Equilíbrio Reflexivo Estrito" e "Equilíbrio Reflexivo Amplo" e, finalmente, algumas aplicações do próprio Rawls na discussão da eugenia e aborto. Na segunda parte, discute-se as extensões feitas por Norman Daniels da teoria da justiça de Rawls, suas aplicações do método e suas próprias contribuições (...) para a bioética, principalmente para a construção de um sistema de saúde justo. Na terceira parte, aborda-se a adoção do método pelos principialistas Beauchamp e Childress. Na parte conclusiva, algumas críticas feitas ao método são avaliadas a partir das aplicações feitas à questões de bioética. (shrink)

Many people working in bioethics take pride in the subject’s embrace of a wide range of disciplines. This invites questions of what in particular is added by each. In this paper, I focus on the role of philosophy within the field: what, if anything, is its unique contribution to bioethics? I sketch out a claim that philosophy is central to bioethics because of its particular analytic abilities, and defend its place within bioethics from a range of sceptical attacks.

Many normative theorists want to contribute to making the world a better place. In recent years, it has been suggested that to realise this ambition one must start with an adequate description of real-life practices. To determine what should be done, however, one must also fundamentally criticise existing moral beliefs. The method of reflective equilibrium offers a way of doing both. Yet, its practical usefulness has been doubted and it has been largely ignored in the recent practical turn of normative (...) theorising. This paper offers a complementary methodology to the method of reflective equilibrium, referred to as Rawlsian constructivism, which brings forth its practical merits. With the support of Rawlsian constructivism, the method of reflective equilibrium becomes a tool for public reasoning about practical problems which aims to facilitate shared solutions. The process of reflective scrutiny is used, not in the search of moral truth, but rather to highlight what stands in the way of solutions to problems agents face in different domains of social life. The practical value lies in scrutinising reasons for action that are taken for granted, explicating new rationales for action and highlighting neglected points of agreement. The paper exemplifies this approach with a process of justifying individual obligations to combat climate change. Normative theorists who share the practical agenda have correctly noted the importance of bottom-up investigations of subject domains. This paper argues that the next step should be to utilise this version of the method of reflective equilibrium to explore the potential for morally progressive solutions to these problems. (shrink)

The article examines the new discourse on medical professionalism and responsibility through the prism of conflicts among moral values, especially with regard to truth-telling. The discussion is anchored in the renaissance of English-language writing on medical ethics in the 18th century, which paralleled the rise of humanitarianism and the advent of the word “responsibility”. Following an analysis of the meanings of the value of responsibility in general and in medical practice in particular, it is argued that, similarly to the Aristotelian (...) notion of equity, responsibility of care is a second-order value, which corrects virtues, laws and norms in exceptional circumstances. Virtues and practices of the second order, such as responsibility and deliberation, bear especially on professional doctoring, which includes a commitment to give priority to the good of the patient over one’s own good. It is argued that, in situations of conflict, and particularly conflicts between personal moral identity and the good of patients, the fundamental professional commitment is to critical and rational deliberation and to the cultivation of psycho-moral flexibility. This leads indirectly to moral growth and strengthening of professional character. (shrink)

Although both codes of practice and virtue ethics are integral to the ethos and history of “medical professionalism”, the two trends appear mutually incompatible. Hence, in the first part of the paper we explore and explicate this apparent conflict and seek a direction for medical education. The theoretical and empirical literature indicates that moral deliberation may transcend the incompatibilities between the formal and the virtuous, may enhance moral and other aspects of personal sensitivity, may help design and improve other parts (...) of the curricula, and may foster self-awareness and clarification of the professional role. Not only are these goals essential for good and conscientious doctoring, but they may also reduce physicians’ “burn-out”. We argue that medical education should focus on the ubiquitous practice of deliberation in contemporary medicine, and especially the practice of moral deliberation. (shrink)

In this commentary, I critically discuss the respective views of Gert and Beauchamp–Childress on the nature of so-called common morality and its promise for enriching ethical reflection within the field of bioethics. Although I endorse Beauchamp and Childress’ shift from an emphasis on ethical theory as the source of moral norms to an emphasis on common morality, I question whether rouging up common morality to make it look like some sort of ultimate and universal foundation for morality, untouched by the (...) dialectics of time and reflective equilibrium, was an equally good move. As for Gert’s magisterial conception of common morality, I conclude that certain elements of his system are controversial at best and woefully inadequate at worst. He has a tendency to find in common morality what he himself put there, and his highly restricted conception of duties of assistance strikes this reader as ad hoc, inadequately defended, and unworthy of a project whose goal is to lessen the amount of misery in the world. (shrink)

The central question for this dissertation is, how do we do moral philosophy well from within a broadly naturalist framework? Its main goal is to lay the groundwork for a methodological approach to moral philosophy that integrates traditional, intuition-driven approaches to ethics with empirical approaches that employ empirical data from biology and cognitive science. Specifically, it explores what restrictions are placed on our moral theorizing by findings in evolutionary biology, psychology, neuroscience, and other fields, and how we can integrate this (...) data while still offering a fully normative account of ethics. To that end, the dissertation explores the methodological assumptions behind both traditional and more empirical or experimental approaches to ethics, to find where these assumptions cannot be properly supported and need to be re-examined. Chapter 1 explores the science-based objections that have been raised to traditional approaches, with a particular focus on questions concerning the reliability of moral intuitions. Chapter 2 examines three fundamental assumptions supporting the empirical approach to moral philosophy, and how those assumptions ultimately do not fit with how we ought to understand the project of ethics. In chapter 3, I discuss the fact/value distinction, and the restrictions that are placed on our moral theorizing by our commitment to this distinction. Chapter 4 offers a defense of ‘companions in guilt’ arguments, and uses these arguments to draw an analogy between moral philosophy and epistemology that will be used to help defend moral philosophy against empirical debunking arguments. Chapter 5 explores the ways in which epistemologists’ methods of incorporating empirical data into their research while maintaining the normativity of their accounts can be adapted to allow moral philosophers to do the same, and brings together the various methodological concerns addressed up to this point to lay out a methodological approach I call empirically-informed moral philosophy. (shrink)

Most philosophical accounts of human rights accept that all persons have human rights. Typically, ‘personhood’ is understood as unitary and binary. It is unitary because there is generally supposed to be a single threshold property required for personhood. It is binary because it is all-or-nothing: you are either a person or you are not. A difficulty with binary views is that there will typically be subjects, like children and those with dementia, who do not meet the threshold, and so who (...) are not persons with human rights, on these accounts. It is consequently unclear how we ought to treat these subjects. This is the problem of marginal cases. I argue that we cannot resolve the problem of marginal cases if we accept a unitary, binary view of personhood. Instead, I develop a new non-binary personhood account of human rights, and defend two main claims. First, there are many, scalar properties, the having of which are conducive to personhood. Second, different subjects have different human rights depending on which of these properties they have, and what threats apply to them. On my view, and contra most existing accounts, most marginal cases have some degree of personhood and are entitled to some human rights. (shrink)

This paper proposes a Rawlsian conception of moral justification as a social activity. Through a close reading, Rawls’ view of ethical justification is shown to be significantly more dialogical and deliberative than is commonly appreciated. The result is a view that emphasizes the social nature of ethical justification and identifies information sharing between persons as the crux of justification in metaethics, in contrast to normative ethics. I call it Rawlsian reflective equilibrium to distinguish it from other varieties.