A diverse group of scholars reflect on the scholarship of Robert M. Veatch, the breadth of which is unmatched in modern day bioethics. Essays were written by both philosophers and clinician-philosophers, by contemporaries and mentees. They span the breadth of Bob’s work and include analyses of his ideas about death, dying and organ transplantation, human experimentation and research ethics, disability, equality and justice, the doctor-patient relationship, the history of bioethics, as well as his pedagogical approach to teaching bioethics to clinicians (...) across the health care spectrum. Recognition of Bob’s influence in the modern field of bioethics and the challenges that persist are clearly identified. (shrink)

Direct-to-consumer pharmaceutical advertising is pervasive in the United States. Beyond its effect on consumer behavior, DTCPA changes the relationship between individuals and physicians. The author provides a brief history of pharmaceutical advertising in the United States. The author then analyzes the current commonly used marketing techniques of pharmaceutical companies and argues that pharmaceutical companies are “irrational authorities” in Erich Fromm’s sense of the term since they seek to exploit persons. Using concepts from various philosophers from the Continental tradition, with a (...) particular emphasis on the work of Michel Foucault, the author analyzes the power relations involved in DTCPA and ultimately argues that DTCPA subtly undermines the contemporary paradigm of patient autonomy while simultaneously depending upon it by treating health consumers as “dividuals,” that is, as porous entities to be manipulated. (shrink)

When the phrase “playing God” is used in debates concerning the use of new technologies, such as cloning or genetic engineering, it is usually interpreted as a warning not to interfere with God’s creation or nature. I think that this interpretation of “playing God” arguments as a call to non-interference with nature is too narrow. In this paper, I propose an alternative interpretation of “playing God” arguments. Taking an argumentation theory approach, I provide an argumentation scheme and accompanying critical questions (...) that capture the moral concerns expressed by “playing God” arguments. If I am right, then “playing God” arguments should be understood, not as a warning to leave God’s creation or nature alone, but rather as an invitation to think carefully about all the ways in which the use of new technologies could go seriously wrong. (shrink)

Patient safety is a central aspect of healthcare quality, focusing on preventable, iatrogenic harm. Harm, in this context, is typically assumed to mean physical injury to patients, often caused by technical error. However, some contributions to the patient safety literature have argued that disrespectful behavior towards patients can cause harm, even when it does not lead to physical injury. This paper investigates the nature of such dignitary harms and explores whether they should be included within the scope of patient safety (...) as a field of practice. We argue that dignitary harms in health care are—at least sometimes—preventable, iatrogenic harms. While we caution against including dignitary harms within the scope of patient safety just because they are relevantly similar to other iatrogenic harms, we suggest that thinking about dignitary harms can help to elucidate the value of patient safety, and to illuminate the evolving relationship between safety and quality. (shrink)

If we are responsible for taking care of our health, are we blameworthy when we become sick because we failed to meet that responsibility? Or is it immoral to blame the victim of sickness? A moral perspective that is sensitive to therapeutic concerns will downplay blame, but banishing all blame is neither feasible nor desirable. We need to understand the ambiguities surrounding moral responsibility in four contexts: (1) preventing sickness, (2) assigning financial liabilities for health care costs, (3) giving meaning (...) to human suffering, and (4) interacting with health care professionals. We also need to distinguish different kinds of blame, explore the interplay of justice and compassion in avoiding unjustified blaming of victims, and work toward a unified moral-therapeutic perspective that encourages individuals to accept responsibility while avoiding destructive forms of blaming. (shrink)

Background: Visual technologies are central to youth culture and are often the preferred communication means of adolescents. Although these tools can be beneficial in fostering relations, adolescents’ use of visual technologies and social media also raises ethical concerns. Aims: We explored how school public health nurses identify and resolve the ethical challenges involved in the use of visual technologies in health dialogues with adolescents. Research design: This is a qualitative study utilizing data from focus group discussions. Participants and research context: (...) We conducted focus group discussions using two semi-structured discussion guides with seven groups of public health nurses working in Norwegian school health services. The data were collected during January and October 2016. Discussions were audio recorded, transcribed, and coded into themes and subthemes using systematic text condensation. Ethical considerations: The leader of the public health nursing service who agreed to provide access for the study and the Norwegian Center for Research Data that reviewed and approved the study. All participants gave informed consent. Findings: In adolescents’ use of visual materials with public health nurses, ethical concerns were raised regarding suicide ideations, socially unacceptable content, violation of privacy, and presentations of possible child neglect. The nurses utilized their professional knowledge and experience when identifying and navigating these ethical dilemmas; they resolved ethical uncertainties through peer discussion and collaboration with fellow nurses and other professionals. Discussion: We discussed the findings in light of Annemarie Mol’s interpretation of the ethics of care. Mol expands the notion of ethical care to include the action of technologies. Conclusion: Although the increasing use of visual technologies offered benefits, school nurses faced ethical challenges in health dialogues with adolescents. To address and navigate these ethical issues, they relied on their experience and caring practices based on their professional ethics. Uncertainties were resolved through peer dialogue and guidance. (shrink)

The clinical relationship has been underexplored in dementia care. This is in part due to the way that the clinical relationship has been articulated and understood in bioethics. Robert Veatch’s social contract model is representative of a standard view of the clinical relationship in bioethics. But dementia presents formidable challenges to the standard clinical relationship, including ambiguity about when the clinical relationship begins, how it weathers changes in narrative identity of patients with dementia, and how the intimate involvement of family (...) fits alongside a paradigmatically dyadic relationship. Drawing on work in recent feminist theory, a critique is offered of the standard clinical relationship in bioethics as underwritten by an individualistic conception of autonomy. An alternative view of the clinical relationship in dementia, one that embraces a relational account of autonomy, is put forward. (shrink)

Decisions on older people’s fitness to drive an automobile are in many cases evaluative and normative. These challenging decisions need to be made at both policy and individual levels. With an ageing population, it is important that this decision-making about older drivers is appropriate and fair, but little work has examined the ethical values that should inform our approach to this issue. This essay concerns the ethical values and framework around older people and driving. I argue that decision-making about older (...) drivers should include a consideration of older people’s mobility and the promotion of individual welfare. Drawing on empirical insights and ethical theory, this essay firstly argues that a traditional safety-focused perspective on older drivers is potentially deficient, misleading, and detrimental, and should be rethought. Secondly, it is shown that driving is both instrumentally and essentially linked to older people’s welfare. Decision-making should therefore include an ethical principle of beneficence. And thirdly, it is argued that a consideration of individual welfare in decisions about older drivers is vital to address important societal trends. (shrink)

Robert Veatch’s The Foundations of Justice: Why the Retarded and the Rest of Us Have Claims to Equality delves into deep questions of justice through the case of a child with disabilities. I describe what is basically right about this vision, as well as what is problematic from the standpoint of contemporary disability bioethics. From there, I dive into the notion of vulnerability that is at play in his work. He describes disability as necessarily a condition of weakness, lesser-than existence, (...) and neediness. When disability is viewed in this way as an inherently vulnerable state of being, the essential sociopolitical dimensions of disability receive inadequate attention, which, in turn, makes it impossible to identify injustices correctly. I connect these points to concrete challenges faced by disability communities during the COVID-19 pandemic, which have raised profound questions about the just use of scarce critical care resources. Any case drawn from the pandemic is a very different kind of case than that of the child in Veatch’s book, but a commonality is the question of who should get what limited resources when needs and urgency vary. (shrink)

Respect for human embryos is often defended on the basis of the potentiality argument: embryos deserve respect because they already possess potentially the features that in adults are fully actualized. Opponents of this argument challenge it by claiming that if embryos should be respected because they are potentially adults, then gametes should be respected because they are potentially embryos. This article rejects this reductio ad absurdum argument by showing that there are two different types of potentiality involved so that the (...) transitivity of potentiality does not hold up in this case. Respect for embryos does not logically entail respect for gametes. (shrink)

The global increase in patients with chronic conditions has led to increased interest in ethical issues regarding such conditions. A basic biomedical principle—respect for autonomy—is being reexamined more critically in its clinical implications. New accounts of this basic principle are being proposed. While new accounts of respect for autonomy do underpin the design of many public programs and policies worldwide, addressing both chronic disease management and health promotion, the risk of applying such new accounts to clinical setting remain understudied. However, (...) the application of new accounts of respect for autonomy to clinical settings could support disrespectful attitudes toward or undue interference with patients with chronic conditions. Reconsidering autonomy and respect using Kantian accounts, this paper proposes respect for persons as an alternative basic bioethical principle to respect for autonomy. Unlike the principle of respect for persons in the Belmont Report, our principle involves respecting any patient’s decisions, behaviors, emotions, or life-style regardless of his or her “autonomous” capabilities. Thus, attitudes toward patients should be no different irrespective of the assessment of their decisional or executive capabilities. (shrink)

In end-of-life care discussions, I contend that the distinction between “having a life” vs. “being alive” is an underutilized distinction. This distinction is significant in separating different states of existence conflated by patients, families, and clinicians. In the clinical setting, applying this distinction in end-of-life care discussions aids patients’ and family members’ decision-making by helping them understand that being alive can differ from having a life. Moreover, this distinction helps them decide which state may be the most important to them. (...) After applying this distinction to three complex cases, I respond to the likely objection that “having a life” vs. “being alive” is less accurate and more controversial than other distinctions. I conclude by arguing that “having a life” vs. “being alive” is more accurate and less controversial than distinctions between medically indicated vs. medically inappropriate treatments, personhood, and quantity vs. quality of life. (shrink)

With few exceptions, the literature on withdrawing and withholding life-saving treatment considers the bare fact of withdrawing or withholding to lack any ethical significance. If anything, the professional guidelines on this matter are even more uniform. However, while no small degree of progress has been made toward persuading healthcare professionals to withhold treatments that are unlikely to provide significant benefit, it is clear that a certain level of ambivalence remains with regard to withdrawing treatment. Given that the absence of clinical (...) benefit means treating patients is not only ethically questionable but also taxing on resources that could meet the needs of others, this ambivalence is troubling. Equally, the enduring ambivalence of professionals might be taken to indicate that the issue warrants further attention. In this paper, we review the academic literature on the ethical equivalence of withdrawing and withholding medical treatment. While we are not in outright disagreement with the arguments presented, we suggest that asserting theoretical and decontextualized claims about the ethical equivalence of withdrawing and withholding life-saving treatment does not fully illuminate the moral questions associated with the relevant clinical realities. We argue that what is required is a broader perspective, one rooted in an understanding that withdrawing and withholding life-saving treatment are different practices, the meanings of which are fully comprehensible only through an appreciation of their place within the practice of healthcare more generally. Such an account suggests that if one is to engage with the inappropriate protraction of life-saving treatment resulting from healthcare professionals’ disinclination to withdraw it, then the differences between these practices should be taken seriously. (shrink)

This essay appreciatively and critically engages the late Robert Veatch’s extensive and important contributions to transplantation ethics, in the context of his overall ethical theory and his methods for resolving conflicts among ethical principles. It focuses mainly on ways to obtain and allocate organs from deceased persons, with particular attention to express donation, mandated choice, and presumed consent/routine salvaging in organ procurement and to conflicts between medical utility and egalitarian justice in organ allocation. It concludes by examining the unclear relations (...) between Veatch’s ideal moral theory and his nonideal moral theory, especially in organ allocation. (shrink)

The day-to-day work of clinical ethics consultants and healthcare ethics committees can easily become overly routine. Too much routine, however, comes with a risk that morally important practices will be reduced to mere bureaucratic formalities, while practitioners become desensitized to ethically significant distinctions between cases. Clinical ethics consultation and organizational ethics must be set within the broader social and cultural context of the healthcare environment. This practice requires looking beyond mere legal compliance and the routinely false assumption that there are (...) unambiguous ethical norms that easily govern clinical ethics and hospital policy formation. Together the essays in this issue of HEC Forum challenge readers to rethink taken-for-granted assumptions regarding patient care, physician obligation, clinical ethics consultation, and organizational ethics. (shrink)

Bioethics functions within a world of deep moral pluralism; a universe of discourse debating ethical analysis, public policy, and clinical practice in which a common, generally accepted morality does not exist. While religious thinkers are often approached within a hermeneutic of suspicion for assuming moral standards that cannot be justified in rational terms, secular bioethicists routinely find themselves in exactly the same intellectual predicament. That ethical theory, proposed values, or normative content is secular, that it does not invoke God or (...) any particular religious perspective, does not mean that it is rationally grounded, necessarily true, or universally binding. As the authors in this issue of The Journal of Medicine and Philosophy make clear, this normative reality directly impacts debates regarding concepts of health, illness, and disease, accounts of socially acceptable health-risky behaviors, and the political frameworks that shape public policy. As a result, honest discussion of diverse moral, religious, and political perspectives remains essential in clarifying the intellectual challenges, ethical intuitions, and ideological judgments that shape clinical practice and healthcare policy. Depending on which moral, political, or scientific concepts are guiding bioethical analysis, careful scrutiny will tend to support rather different policies and practices, each of which is likely to be worth careful consideration. (shrink)

This article describes and rejects three standard views of reason in secular clinical ethics. The first, instrumental reason view, affirms that reason may be used to draw conceptual distinctions, map moral geography, and identify invalid forms of argumentation, but prohibits recommendations because reason cannot justify any content-full moral or metaphysical commitments. The second, public reason view, affirms instrumental reason, and claims ethicists may make recommendations grounded in the moral and metaphysical commitments of bioethical consensus. The third, comprehensive reason view, also (...) affirms instrumental reason, but encourages ethicists to make recommendations grounded in the moral and metaphysical commitments of their private worldviews. A compatibilist view of public reason is then defended, which holds that each standard view captures an important role for reason in different aspects of secular clinical ethics. The article ends by identifying three implications for enduring theoretical debates in clinical ethics. (shrink)

What is the proper role of a clinical ethics consultant’s religious beliefs in forming recommendations for clinical ethics consultation? Where Janet Malek has argued that religious belief should have no influence on the formation of a CEC’s recommendations, Clint Parker has argued a CEC should freely appeal to all their background beliefs, including religious beliefs, in formulating their recommendations. In this paper, I critique both their views by arguing the position envisioned by Malek puts the CEC too far from religion (...) and the position envisioned by Parker puts the CEC too close. For a CEC to give recommendations about what is morally prohibited, permissible, or obligatory in the clinic, I propose a view of the CEC that is neither religious nor non-religious but quasi-religious. I argue that a quasi-religious approach avoids the problems of both religious and non-religious views while preserving their benefits. Additionally, a quasi-religious view resists the marginalization of “religious” traditions that occurs when secular ethicists come to think of their approach as somehow distinctly non-religious. (shrink)

The national standards for clinical ethics consultation set forth by the American Society for Bioethics and Humanities endorse an “ethics facilitation” approach, which characterizes the role of the ethicist as one skilled at facilitating consensus within the range of ethically acceptable options. To determine the range of ethically acceptable options, ASBH recommends the standard model of decision-making, which is grounded in the values of autonomy, beneficence, nonmaleficence, and justice. H. Tristram Engelhardt Jr. has sharply criticized the standard model for presuming (...) contentful moral claims in circumscribing the range of ethically acceptable options, which, he argues, cannot be rationally justified in a pluralistic context. Engelhardt’s solution is a secular clinical ethics based on a contentless principle of permission. The first part of this article lays out Engelhardt’s negative claim, that reason cannot establish contentful moral claims, and his positive claim, that secular clinical ethics ought to be based on a contentless principle of permission. The second part critiques these negative and positive claims. The purpose of this paper is to defend secular clinical ethics expertise—defined as the ability of ethicists to offer justified moral recommendations grounded in consensus positions endorsed by the American Society for Bioethics and Humanities—from the radical critiques of Engelhardt, who argues that no moral or metaphysical claims, and hence no bioethical consensus, can be rationally justified. Engelhardt’s critiques have caused some to worry that secular clinical ethics is in a state of theoretical crisis; this article concludes that Engelhardt’s view is an unstable basis for that worry. (shrink)

Roughly 80,000 U.S. prisoners are held in solitary confinement at any given time. A significant body of research shows that solitary confinement has severe, long-term effects, and the United Nations has condemned the practice of solitary confinement as torture. For years, prisoners have been organizing hunger strikes in order to protest solitary confinement. But such action is not without consequences, and some inmates have suffered serious injury or death. The question I raise in this paper is whether we ought to (...) force-feed hunger striking prisoners when serious harm is imminent. Both the World Medical Association and the American Medical Association have denounced the practice of force-feeding prisoners on hunger strike, and yet, the practice is common. Such prevalence is likely a result of the tension between the person-as-patient and person-as-prisoner and cannot easily be resolved. Instead, we must take seriously the complaint that solitary confinement is inhumane and avoid placing health professionals in the position where they must choose to force-feed the prisoner against his will or not. I argue that a conventional bioethics debate centering on polarizing principles of prisoner autonomy and a duty-to-protect the prisoner from harm is an inadequate framework for this complex issue. Instead, we must examine the prisoner’s intent and his right to freedom of speech. I argue that when the prisoner’s intent is to raise awareness and communicate with others, his hunger strike is a form of speech. Protest-as-speech is constitutionally protected—even for prisoners—and remains a minimum ethical obligation for society to uphold. (shrink)