The structure, content, and orientation of the contemporary medical record inadequately reflect the appropriate influence of patients' rights and bioethics on health care. Most tellingly, the medical chart reveals a remarkable absence of attention to medical ethics, except in the case of crisis management. But medical ethics informs both crisis decision-making and virtually all clinical interventions. Indeed, clinical care embodies a complex array of choices influenced by individual and cultural values, themselves reflecting religious beliefs, personal histories, psychologies, and social mores. (...) But the typical medical chart, which records clinical descriptions, analyses, and rationales for treatment, rarely identifies or accounts for this value-laden dimension of care and thus both over-simplifies and distorts the depiction of a patient's illness and its treatment. To better reflect the complex moral domain of clinical care, and assist in organizing its complex structure, a systematic procedure is proposed here to evaluate the ethical status of every patient: As a routine part of the clinical evaluation, in a designated Ethical Concerns section of the medical record, an ?ethics work-uP? is designed to serve as a moral ?diagnostic? analogous to its scientific counterpart. Adapted to the needs of individual patients, such evaluations should identify ethical problems, coordinate related data, resources, and opinion, and define the rationale for choices made and actions pursued. In establishing improved integration of the ?epistemologies? of care and the ?ethics? of care, the goals of a more humane, patient-centered medicine may be better met. (shrink)

In the 17th century, ‘reflexivity’ was coined as a new term for introspection and self-awareness. It thus was poised to serve the instrumental function of combating skepticism by asserting a knowing self. In this Cartesian paradigm, introspection ends in an entity of self-identity. An alternate interpretation recognized how an infinite regress of reflexivity would render ‘the self’ elusive, if not unknowable. Reflexivity in this latter mode was rediscovered by post-Kantian philosophers, most notably Hegel, who defined the self in its self-reflective (...) encounter with an other, and whose full articulation would occur at the final culmination of Reason's evolution. In the rising tide of 19th-century individualism, Emerson and Kierkegaard formulated constructions both in debt to, and in opposition against, Hegelian metaphysics. For each, although employing distinct strategies of self-consciousness, ‘the self’ reached its apogee through divine encounter. Characterized by personal responsibility and individual choice, their philosophies would later be subsumed by secular existentialists committed to defining moral individualism and asserting the possibilities for human freedom and selfauthentication. (shrink)

An autobiographical account is offered of how the medical study of self (immunology) became a chapter in the philosophical study of human agency (from Nietzsche and Thoreau to Freud by way of Wittgenstein). Whether viewed scientifically or philosophically, several themes converge on the intractable instability of any notion of selfhood—epistemological or moral. How this problematic motivated an extended analysis of selfhood refracts the psychology of the author and his pursuit of philosophy as self‐knowledge.

In the article I discuss three types of non-formal curriculum: the hidden, informal and null curriculum. Their negative impact on the moral education of medical students and physicians is documented through the choice of examples from Polish medical schools and the statements of Polish physicians. I also justify the thesis that the teaching of medical ethics as ethics-as-tools is deeply rooted within the Polish moral cultural tradition. The polemic with Władysław Biegański serves as a means of showing the relation between (...) the medical moral tradition and the belief that medical ethic is of little importance in the moral education of medical students and doctors. I also indicate that the lack of references to medical schools as moral entities within moral education condemns physicians to the solitude of their personal conscience when confronted with moral decisions. This, in turn, promotes the idea of defining this conscience in opposition to the law. (shrink)

W pierwszej części artykułu charakteryzuję trzy rodzaje profesjonalizmu lekarskiego: profesjonalizm tradycyjny, odnowiony i kompleksowy. Omawiam także czynniki kulturowe, ekonomiczne i aksjologiczne wpływające na ich kształtowanie się. Stawiam tezę, że profesjonalizm kompleksowy ze względu na jego skomplikowanie i arbitralne wyodrębnianie elementów składowych jest nieprzydatny w edukacji moralnej studentów i lekarzy. W części drugiej rekonstruuję wady i zalety profesjonalizmu tradycyjnego i odnowionego. Uzasadniam pogląd, że najważniejsza zaleta profesjonalizmu wynika z jego ambiwalencji moralnej. Nie traktuję więc tej dwuznaczności jako wyłącznie wady. Lekarz profesjonalista (...) powinien mieć świadomość jasnych i ciemnych stron profesjonalizmu oraz umiejętność właściwego ich ważenia w danych okolicznościach – poszukiwania Arystotelesowskiego złotego środka. W ostatniej części argumentuję za umiarkowanie optymistycznym przekonaniem o przydatności profesjonalizmu tradycyjnego i odnowionego w moralnym formowaniu studentów medycyny i młodych lekarzy. (shrink)

Whereas in the 1970s early bioethicists believed that bioethics is an arena for the application of philosophical theories of utilitarianism, deontology, and natural law thinking, contemporary policy-oriented bioethicists seem rather to be keen on framing ethical issues through political ideologies. Bioethicists today are often labeled “liberal” or “communitarian,” referring to their different understandings of the relationship between the individual and society. Liberal individualism, with its conceptual base of autonomy, dignity, and privacy, enjoyed a long period of dominance in bioethics, but (...) it has increasingly come under attack from ideologies promoting a more salient role for concepts of solidarity, community, and public interest. (shrink)

Purpose Although the term “responsibility” plays a central role in bioethics and public health, its meaning and implications are often unclear. This paper defends the importance of a more systematic conception of responsibility to improve moral philosophical as well as descriptive analysis. Methods We start with a formal analysis of the relational conception of responsibility and its meta-ethical presuppositions. In a brief historical overview, we compare global-collective, professional, personal, and social responsibility. The value of our analytical matrix is illustrated by (...) sorting out the plurality of responsibility models in three cases (organ transplantation, advance directives, and genetic testing). Results Responsibility is a relational term involving at least seven relata. The analysis of the relata allows distinguishing between individual versus collective agency, retrospective versus prospective direction, and liability versus power relations. Various bioethical ambiguities result from insufficient, implicit, or inappropriate ascriptions of responsibility. Conclusions A systematic conception of responsibility is an important tool for bioethical reflection. It allows an in-depth understanding and critique of moral claims on a meta-ethical level without presuming one particular normative approach. Considering the concept of responsibility can also help to complement the current bioethical focus on individual autonomy by including the perspectives of other actors, such as family members or social groups. (shrink)

With the growing focus on prevention in medicine, studies of how to describe risk have become increasing important. Recently, some researchers have argued against giving patients “comparative risk information,” such as data about whether their baseline risk of developing a particular disease is above or below average. The concern is that giving patients this information will interfere with their consideration of more relevant data, such as the specific chance of getting the disease (the “personal risk”), the risk reduction the treatment (...) provides, and any possible side effects. I explore this view and the theories of rationality that ground it, and I argue instead that comparative risk information can play a positive role in decision-making. The criticism of disclosing this sort of information to patients, I conclude, rests on a mistakenly narrow account of the goals of prevention and the nature of rational choice in medicine. (shrink)

For at least the past several decades, medicine has been embroiled in a crisis concerning the nature of its professionalism. The fundamental questions that drive this ongoing crisis are primarily three. First, what is the nature of medical professionalism? Second, who are medical professionals? Third, what does medicine or these professionals profess or promise? In this paper, the professionalism crisis vis-à-vis these questions is examined and analyzed chiefly in terms of both Francis Peabody’s and Edmund Pellegrino’s writings. Based on their (...) writings, I introduce a conceptual framework for professionalism to address the crisis. In addition, I contend that to address the professionalism crisis adequately, medicine’s position within an evolving health care network must also be considered. To that end, I first discuss the genesis of the crisis in terms of the Flexner Report and especially Peabody’s response to it. Next, I explore how the crisis intensified during the twentieth century, particularly in terms of medicine’s ultimate scientification and eventual commercialization, and how Pellegrino reacted to this. I then propose a health care professionalism cycle and a care-competence cycle to provide a conceptual framework for addressing the crisis. I conclude that medicine’s position is no longer as the center of health care but rather as another node within a wider evolving health care network. And the resolution of medicine’s professionalism crisis depends on medicine’s positioning and defining itself in terms of the professionalism for each of the other professions within the health care network. (shrink)

This essay explores the two main objectives of Bishop’s book, which he analyzes in the context of the care for the dying: the medical metaphysics underlying medical science and biopolitics as governance of the human body. This essay discusses Bishop’s claims in view of newer developments in medicine, especially the turn to the construction of life, and confronts the concept of the patient’s sovereignty with an alternative model of vulnerable agency. In order to overcome the impasses of contemporary bioethics, the (...) essay argues that practical reason requires a two-fold ethics: first, it must develop a new hermeneutics of illness and disease, and second, in order to protect the individuals in the process of dying, moral claims concerning death must be based on the concept of human rights. (shrink)

Background The case of Margaret Haywood, the ‘undercover nurse’, is a significant one for the UK's National Health Service (NHS). She investigated complaints made about the Royal Sussex County Hospital and covertly filmed inpatients experiencing care detrimental to their health. The material was subsequently broadcast on the BBC's Panorama programme. It caused a scandal and brought about changes at the hospital, as well a demand for greater clinical leadership. Margaret Haywood was, however, struck off the nursing register for breaching confidentiality (...) and because of the methods she used to blow the whistle. Methods The authors apply the ethical lenses of purpose, principle, people and power to explore this case. Results This is a morally ambiguous situation in which both the protagonist and the organisation compromised their core values. The undercover nurse used individuals as a means to a ‘higher’ end, and the Brighton and Sussex University Hospitals NHS Trust are seen to have deviated from the ethical to the business map, in a contradiction of what the health service represents. Conclusions These deficits can be repaired by reinforcement of the ethics of duty and ideals on a practical level and the involvement of clinicians to lead at a management level, to act as a moral compass. (shrink)

During the past few months, the discussion over the physicians' “Right of Conscience” has been on the rise. The intervention of politics in this issue shifts the discussion to a very specific and narrow area, namely the “reproductive health laws” which bear well-known predisposing attitudes.In this article, the physician's ROC is discussed in the context in which it naturally belongs: the Patient Physician Relationship . I suggest that the physicians' rights demand is a comprehensible, predictable, and even inevitable step as (...) part of the “evolution” of the PPR. Thus, the most appropriate way to comprehend and tackle the demand for physicians' ROC is within the context of medical professionalism. While searching for practical solutions to the “reproductive health” problems, there is a need to recognize the ethical and practical implications of the change in the PPR and balance between patient and physician rights. (shrink)

Recently, the discussion regarding the physicians’ “Right of Conscience” has been on the rise. This issue is often confined to the “reproductive health” arena within the political context. The recent dispute of the Bush-Obama administrations regarding the legal protections of health workers who refuse to provide care that violates their personal beliefs is an example of the political aspects of this dispute. The involvement of the political system automatically shifts the discussion regarding physicians’ ROC into the narrow area of “reproductive (...) health laws.” Indeed, the immediate association that comes to mind when thinking about the practical implications of this dispute is related to the reproductive health arena. This is partly because of the historical context of the first “conscience clauses,” initially enacted by Congress and state legislatures in the mid-1970s; in fact, most of these clauses provided specific exemptions for abortion and few exempted sterilization as well. (shrink)

Questions about the nature of self and self-consciousness are closely aligned with questions about the nature of autonomy. These concepts have deep roots in traditional philosophical discussions that concern metaphysics, epistemology and ethics. They also have direct relevance to practical considerations about informed consent in medical contexts. In this paper, with reference to understanding specific side effects of deep brain stimulation treatment in cases of, for example, Parkinson’s Disease, Obsessive Compulsive Disorder, and Major Depressive Disorder, I’ll argue that it is (...) best to frame discussions of informed consent in terms of relational autonomy and a pattern theory of self. (shrink)

Although bioethics is a lively and expanding interdisciplinary field, there is not enough research about the patient‐doctor relationship, a central issue in philosophy of medicine. This article surveys the state of the field, paying attention to recent work by Alfred Tauber, and supplementing it with insights from Hans Jonas's philosophy of technology in order to propose a principle of responsible autonomy for health care. Based on a comparative look across different sub‐fields in bioethics, the resulting model claims that physician responsibility (...) is essential to professional integrity, providing an alternative to other active trends emphasizing patient autonomy, such as Robert Veatch's contractual model. (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)

In recent years, several studies have advocated the need to expand the concept of patient autonomy beyond the capacity to deliberate and make decisions regarding a specific medical intervention or treatment (decision-making or decisional autonomy). Arguing along the same lines, this paper proposes a multidimensional concept of patient autonomy (decisional, executive, functional, informative and narrative) and argues that determining the specific aspect of autonomy affected is the first step towards protecting or promoting (and respecting) patient autonomy. These different manifestations of (...) autonomy are not mutually dependent; there may be patients who have problems in one dimension, while at the same time being fully autonomous in others. Nevertheless, a close interaction has been observed between the various dimensions and indeed, a phenomenological analysis shows that damage to or a reduction in one aspect of people’s capacity for self-government generally affects other aspects of their autonomy, which in turn disrupts their identity and the way in which they see themselves and are seen by others. In this paper, I shall examine some of these interactions and show how they may lie at the heart of the problem of poor treatment adherence (where adherence is defined as being the extent to which a patient’s behavior over time coincides with the recommendations made by and agreed with their health professional). One example given is that of psoriasis, a chronic skin disease with a very poor adherence record. In Spain, it is calculated that 85% of patients diagnosed with mild to moderate psoriasis fail to comply properly with their treatment, and figures from other parts of the world are similar. Although there are many possible causes for non-adherence among psoriasis patients, assessing their decisional, executive and narrative capacities and taking appropriate action based on the results may help increase adherence rates. (shrink)

Ontologies describe reality in specific domains in ways that can bridge various disciplines and languages. They allow easier access and integration of information that is collected by different groups. Ontologies are currently used in the biomedical sciences, geography, and law. A Biomedical Ethics Ontology would benefit members of ethics committees who deal with protocols and consent forms spanning numerous fields of inquiry. There already exists the Ontology for Biomedical Investigations (OBI); the proposed BMEO would interoperate with OBI, creating a powerful (...) information tool. We define a domain ontology and begin to construct a BMEO, focused on the process of evaluating human research protocols. Finally, we show how our BMEO can have practical applications for ethics committees. This paper describes ongoing research and a strategy for its broader continuation and cooperation. (shrink)

[Przekład] Autor komentuje zmiany w filozofii immunologii, które zaszły od czasu opublikowania jego książki The Immune Self: Theory or Metaphor?, a także istniejące w tej dziedzinie zagrożenia, nieporozumienia i oczekiwania. Wreszcie – przedstawia w tym kontekście własne ujęcie działania moralnego, odnosząc się do własnych prac.

There is all over the world a sort of fever affecting all the research fields related, closely or somewhat loosely,with human health issues. Some of them – cloning, therapeutic cloning, stem cell therapy, human enhancement, etc. – arise fierce and controversial public debates. At the same time, a concern can be felt worldwide that tomorrow’s medicine might well become more and more « dual », the advanced health devices threatening to become the privilege of a small whealthy minority, or at (...) least excluding the vast majority of the poor and the low middle class. Furthermore, there are even greater disparities between wealthy and poor nations in access to health care and in the level of protection available to members of the latter’s population in a medical context. The theme of rationing health care has been ongoingly gaining in prevalence over the two to three last decades in the public debates, causing many to express worries about the ability of our health system to provide both efficiency and justice in health care. But, among all the new health care devices, are there not some which could be efficient both in terms of improvement of the management of patients’ health and of a just allocation of care ? Besides, not only emerge concerns linked with the development of new technologies in health care, but also in connection with the impact of social-political transformations onto the medical relationship : what are in this context the doctor-patient relationship in regard to autonomy and gender ? Should we be free to use or not to use these new technologies ? Might not the « quest for perfection » develop into a duty of perfection ? And, with the improvement of the therapeutic power to prolong human life, are we to think of assisted suicide as the future of death ? These are some of the issues that this conference wants to adress from an ethical perspective and with rigour. To enrich our discussions also medical and life science praticioners willing to reflect ethically on moral questions of health issues in their professional life and politicians faced with ethical decisions in the domain of health are welcome to participate. (shrink)