In our time there is growing interest in developing a systematic approach to oncologic patients and end-of-life care. An important goal within this domain is to identify the values and ethical norms that guide physicians’ decisions and their recourse to technological aids to preserve life. Though crucial, this objective is not easy to achieve.

BackgroundRadiotherapy is an essential component of cancer treatment, yet many countries do not have adequate capacity to serve all patients who would benefit from it. Allocation systems are needed to guide patient prioritization for radiotherapy in resource-limited contexts. These systems should be informed by allocation principles deemed relevant to stakeholders. This study explores the ethical dilemmas and views of decision-makers engaged in real-world prioritization of scarce radiotherapy resources at a cancer center in Rwanda in order to identify relevant (...) principles.MethodsSemi-structured interviews were conducted with a purposive sample of 22 oncology clinicians, program leaders, and clinical advisors. Interviews explored the factors considered by decision-makers when prioritizing patients for radiotherapy. The framework method of thematic analysis was used to characterize these factors. Bioethical analysis was then applied to determine their underlying normative principles.ResultsParticipants considered both clinical and non-clinical factors relevant to patient prioritization for radiotherapy. They widely agreed that disease curability should be the primary overarching driver of prioritization, with the goal of saving the most lives. However, they described tension between curability and competing factors including age, palliative benefit, and waiting time. They were divided about the role that non-clinical factors such as social value should play, and agreed that poverty should not be a barrier.ConclusionsMultiple competing principles create tension with the agreed upon overarching goal of maximizing lives saved, including another utilitarian approach of maximizing life-years saved as well as non-utilitarian principles, such as egalitarianism, prioritarianism, and deontology. Clinical guidelines for patient prioritization for radiotherapy can combine multiple principles into a single allocation system to a significant extent. However, conflicting views about the role that social factors should play, and the dynamic nature of resource availability, highlight the need for ongoing work to evaluate and refine priority setting systems based on stakeholder views. (shrink)

Healthcare professionals often need to make clinical decisions that carry profound ethical implications. As such, they require a tool that will make decision-making intuitive. While the discussion about the principles that should guide clinical ethics has been going on for over two thousand years, it does not seem that making such decisions is becoming any more straight forward. With an abundance of competing ethical systems and frameworks for their application in real life, the clinician is still often not (...) sure how to proceed in the face of ethical dilemmas, either due to a lack of background ethical knowledge or experience in applying it. This paper will discuss whether considering what one would expect one’s friend to do if one was the patient, or what would one think they would do for a friend if they were the patient, can be a helpful, more intuitive, tool for clinical decision-making that can produce outcomes that are congruent with major ethical systems. (shrink)

Exploring the concepts of ethics, morality, and decision-making for the law enforcement community, Decision Point: Real-Life Ethical Dilemmas in Law Enforcement offers an inside look at the difficult challenges officers confront every day as they face ethical decisions that could drastically alter the course of their careers. Through a series of real-life vignettes, the book reviews specific scenarios, the actual decisions that were made, and the consequences and implications of these decisions. Focusing on the critical (...) thinking needed for making appropriate decisions, it retrospectively discusses considerations that were or should have been evaluated at the time. An engaging text ideal for classroom use, the book offers discussion questions at the end of each chapter that can be used as assignments, group breakout discussions, or professor-facilitated discussions. (shrink)

Through a series of essays and cases based on real-life experiences, this book explores the interrelatedness of ethics and management and helps healthcare professionals at all levels of an organization overcome barriers to ethical decisions.

Philosophers of science have given up on the quest for a silver bullet to put an end to all pseudoscience, as such a neat formal criterion to separate good science from its contenders has proven elusive. In the literature on critical thinking and in some philosophical quarters, however, this search for silver bullets lives on in the taxonomies of fallacies. The attractive idea is to have a handy list of abstract definitions or argumentation schemes, on the basis of which one (...) can identify bad or invalid types of reasoning, abstracting away from the specific content and dialectical context. Such shortcuts for debunking arguments are tempting, but alas, the promise is hardly if ever fulfilled. Different strands of research on the pragmatics of argumentation, probabilistic reasoning and ecological rationality have shown that almost every known type of fallacy is a close neighbor to sound inferences or acceptable moves in a debate. Nonetheless, the kernel idea of a fallacy as an erroneous type of argument is still retained by most authors. We outline a destructive dilemma we refer to as the Fallacy Fork: on the one hand, if fallacies are construed as demonstrably invalid form of reasoning, then they have very limited applicability in real life. On the other hand, if our definitions of fallacies are sophisticated enough to capture real-life complexities, they can no longer be held up as an effective tool for discriminating good and bad forms of reasoning. As we bring our schematic “fallacies” in touch with reality, we seem to lose grip on normative questions. Even approaches that do not rely on argumentation schemes to identify fallacies fail to escape the Fallacy Fork, and run up against their own version of it. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Real-life BioethicsGregory E. KaebnickMy academic training is in philosophy, and I tend to see the problems in bioethics as philosophical problems. And so they often are. What are moral values? What is the nature of rationality? These are certainly philosophical problems. But at the same time, they are not strictly philosophical problems, insofar as they are not the special purview of the field of philosophy. They require (...) a broader treatment, and that broader treatment might even lead us to believe that the standard philosophical treatment is unsatisfactory.In one way or another, several items in this issue of the Hastings Center Report raise questions about the standard philosophical answers to issues in bioethics. The challenge is most explicit in Barry Hoffmaster’s article, “The Rationality and Morality of Dying Children.” Hoffmaster launches a frontal assault on the typical philosophical understanding of ethics, applied ethics, and bioethics. “There is more rationality in our lives than there is in our philosophy,” he begins. The usual take in philosophy on rationality “hides the real nature and extent of the rationality and the morality in our lives because it denigrates, if not ignores, our experience and our creativity.” Closer attention to our experience is therefore needed, and Hoffmaster tries to take a step in that direction by considering anthropological research on how children dying of leukemia learned about their condition and then dealt with that knowledge.The lead article, by Tony Hope and three coauthors, questions standard philosophical approaches to decision-making in a different way. Hope and his colleagues consider whether the concept of authenticity is useful for exploring how patients with anorexia nervosa understand their condition and deal with that knowledge. Further, they ask, if the concept is important for people with anorexia, should it be important for clinicians, who sometimes need to make decisions on behalf of those women? Arguably, they explain, “in respecting autonomy, it is the authentic wishes that should be respected. This would be to give the idea of authenticity a role analogous to that of capacity (competence).”Hope and colleagues are skeptical that “authenticity” can help others make decisions on behalf of women with anorexia nervosa. There is no good way of deciding which decisions would count as “authentic.” But thinking about how to make decisions is not the full extent of bioethics. As the essay by Rebecca Dresser emphasizes, attempting to understand the patient’s experience of illness is another and important part of bioethics, even though bioethicists themselves do not always see it that way. “At times,” writes Dresser, “work in our field conveys the impression that seriously ill patients and their families would be in good shape if clinicians would only do things like give patients the proper information, respect patients’ choices, and follow advance directives.” Just as Hope and colleagues argued for attending more closely to the concept of authenticity, Dresser argues for attending to concepts like dignity, mortality, and grief. These concepts “may be difficult to incorporate into bioethical analysis, but they are the sorts of concerns that matter to people dealing with serious illness.”A bioethics that dealt better with them would still be a philosophical bioethics, but certainly not just a bioethics of philosophy. It would be what Dresser calls a “real-life bioethics.” —GEK [End Page 2]Copyright © 2011 The Hastings Center... (shrink)

This book is a comprehensive, empirically-grounded exploration of the relationship between bioethics, culture, and the perspective of being affected. It provides a new outlook on how complex "bioethical" issues become questions of everyday life. The authors focus on two contexts, genetic testing and end-of-life care, to locate and demonstrate emerging themes of responsibility, such as self-responsibility, responsibility for kin, and the responsibility of society. Within these themes, the duty to know versus the right not to know one's (...) genetic fate (in the context of genetic testing), or the sanctity of life versus self-determination (in the context of end of life care) are identified as culturally embedded dilemmas that are very much relevant for lay persons. Furthermore, cultural factors such as religion, history, utopian and dystopian views of biomedical technologies, outlooks on the body and on health/illness, and citizenship are examined. Health issues are increasingly becoming a question of assessing risk and responsibility: How can we better prepare ourselves for the future? We all make such assessments in a way that combines personal inclinations, professional recommendations, and cultural framings. There is still much to be learned about the interplay between these three dimensions. (shrink)

IntroductionHigh healthcare costs make illness precarious for both patients and their families’ economic situation. Despite the recent focus on the interconnection between health and financial risk at the systemic level, the ethical conflict between concerns for potential health benefits and financial risk protection at the household level in a low-income setting is less understood.MethodsUsing a seven-step ethical analysis, we examine a real-life dilemma faced by families and health workers at the micro level in Ethiopia and analyse the acceptability (...) of limiting treatment for an ill newborn to protect against financial risk. We assess available evidence and ethical issues at stake and discuss the dilemma with respect to three priority setting criteria: health maximisation, priority to the worse-off and financial risk protection.ResultsGiving priority to health maximisation and extra priority to the worse-off suggests, in this particular case, that limiting treatment is not acceptable even if the total well-being gain from reduced financial risk is taken into account. Our conclusion depends on the facts of the case and the relative weight assigned to these criteria. However, there are problematic aspects with the premise of this dilemma. The most affected parties—the newborn, family members and health worker—cannot make free choices about whether to limit treatment or not, and we thereby accept deprivations of people’s substantive freedoms.ConclusionIn settings where healthcare is financed largely out-of-pocket, families and health workers face tragic trade-offs. As countries move towards universal health coverage, financial risk protection for high-priority services is necessary to promote fairness, improve health and reduce poverty. (shrink)

A reductive reading of Humanae vitae seeks to limit its appeal to a ban on contraception. In truth, however, it offers a vision of human sexuality and conjugal love with broad and enduring relevance. In setting forth the intrinsic complementarity and irreducibility of the unitive and procreative dimensions of the conjugal act, Paul VI has given us a hermeneutical key for assessing many contemporary ethical dilemmas in human reproductive medicine. From this perspective, this article seeks to apply the logic (...) of Humanae vitae to several real-life scenarios confronted by medical practitioners, educators, and ethicists working in the field of fertility and reproductive health. These include a consideration of the ethics of prescribing hormonal contraceptives, the possibilities of investigating male infertility, issues of cooperation in counseling and assisting conception in same-sex relationships, the ethics pertaining to assisted reproductive technology, the contested case of prenatal adoption, and the application of double-effect reasoning. On the occasion of the fiftieth anniversary of the promulgation of Pope Paul VI's encyclical Humanae vitae, this article seeks to defend its enduring relevance to modern-day society, through application of its reasoning to contemporary dilemmas in reproductive medicine. It considers real cases of the ethics of prescribing hormonal contraceptives, of investigating male infertility, of cooperating in counseling and assisting conception in same-sex relationships, of ART, of prenatal adoption, and the application of double-effect reasoning. (shrink)

BackgroundThe phenomenon of ‘moral distress’ has continued to be a popular topic for nursing research. However, much of the scholarship has lacked conceptual clarity, and there is debate about what it means to experience moral distress. Moral distress remains an obscure concept to many clinical nurses, especially those outside of North America, and there is a lack of empirical research regarding its impact on nurses in the United Kingdom and its relevance to clinical practice.Research aimTo explore the concept of moral (...) distress in nursing both empirically and conceptually.MethodologyFeminist interpretive phenomenology was used to explore and analyse the experiences of critical care nurses at two acute care trauma hospitals in the United Kingdom. Empirical data were analysed using Van Manen’s six steps for data analysis.Ethical considerationsThe study was approved locally by the university ethics review committee and nationally by the Health Research Authority in the United Kingdom.FindingsThe empirical findings suggest that psychological distress can occur in response to a variety of moral events. The moral events identified as causing psychological distress in the participants’ narratives were moral tension, moral uncertainty, moral constraint, moral conflict and moral dilemmas.DiscussionWe suggest a new definition of moral distress which captures this broader range of moral events as legitimate causes of distress. We also suggest that moral distress can be sub-categroised according to the source of distress, for example, ‘moral-uncertainty distress’. We argue that this could aid in the development of interventions which attempt to address and mitigate moral distress.ConclusionThe empirical findings support the notion that narrow conceptions of moral distress fail to capture the real-life experiences of this group of critical care nurses. If these experiences resonate with other nurses and healthcare professionals, then it is likely that the definition needs to be broadened to recognise these experiences as ‘moral distress’. (shrink)

Buddhists, including the Bhutanese, value human life as rare and precious, and accept sickness, ageing and death as normal aspects of life. However, death and dying are subjects that evoke deep and disturbing emotions often characterised by denial related to high-tech medicalisation and its inspiring hope. Advanced medical interventions such as cardiopulmonary resuscitation are believed to interfere with the natural process of dying. However, some excessively pursue medical interventions in the hope of prolonging and preserving life, refusing (...) its finitude. Healthcare workers are faced with increasing instances of ethical and moral dilemmas exacerbated by inadequate training and lack of proper understanding of the socio-cultural context on end-of-life care and to facilitate good death in Bhutan. We discuss these ethical dilemmas in providing quality end-of-life care and good death against the backdrop of rapidly changing social values and expectations. (shrink)

Metaphors used to describe new technologies mediate public understanding of the innovations. Analyzing the linguistic, rhetorical, and affective aspects of these metaphors opens the range of issues available for bioethical scrutiny and increases public accountability. This article shows how such a multidisciplinary approach can be useful by looking at a set of texts about one issue, the use of a newly developed technique for genetic modification, CRISPRcas9.

Nurses and doctors who deal with human lives have started questioning their own decisions and practices particularly when there is an ethical dilemma. To survive competently within the profession and to make ethical decisions for the client’s safety, one needs to be equipped with knowledge pertaining to Bio-Ethics. This paper brings attention to a real life dilemma of a sixteen year old female child who had been sexually abused by one of her family friends. She insisted the school (...) health nurse to keep the information confidential, particularly from her parents. Consequently, the nurse had to confront a real dilemma regarding the disclosure of information to the parents of the victim. If the nurse respected the client’s autonomy to take her own decisions, then probably she may have put the client’s life at stake as she would not get any support, guidance and protection from further abuse. This paper will examine the role of health nurse or professionals in school setting for client safety. Moreover, this paper will also integrate moral reasoning by using the ethical decision making model by Patricia Chricham from Bioethics discipline. (shrink)

Can the Hippocratic and Judeo-Christian traditions be synthesized with contemporary thought about practical reason, virtue and community to provide real-life answers to the dilemmas of healthcare today? Bishop Anthony Fisher discusses conscience, relationships and law in relation to the modern-day controversies surrounding stem cell research, abortion, transplants, artificial feeding and euthanasia, using case studies to offer insight and illumination. What emerges is a reason-based bioethics for the twenty-first century; a bioethics that treats faith and reason with equal (...) seriousness, that shows the relevance of ancient wisdom to the complexities of modern healthcare scenarios and that offers new suggestions for social policy and regulation. Philosophical argument is complemented by Catholic theology and analysis of social and biomedical trends, to make this an auspicious example of a new generation of Catholic bioethical writing which has relevance for people of all faiths and none. (shrink)

"Teaching College Students How to Solve Real-Life Moral Dilemmas" will speak to the sometimes confounding, real-life, moral challenges that quarterlife students actually face each and every day of their lives. It will spell out an original, all-inclusive approach to thinking about, and applying, ethical problem-solving that takes into consideration people's acts, intentions, circumstances, principles, background beliefs, religio-spiritualities, consequences, virtues and vices, narratives, communities, and the relevant institutional and political structures. This approach doesn't tell students exactly (...) what to do as much as it evokes important information in order to help them think more deeply and expansively about ethical issues in order to resolve actual ethical dilemmas. There is no text like it on the market today. "Teaching College Students How to Solve Real-Life Moral Dilemmas" can be used in a variety of ethics courses. (shrink)

This paper discusses ethical dilemmas related to social work practice with young adults with autism. It does so via the use of a case study taken from real life practice. The different viewpoints and ethical frameworks of the young person, the young person's parents and the Local Authority (or the Local Authority social worker) are considered and discussed. The competing rights of the 2006 United Nations Convention on the Rights of Persons with Disabilities (and the Optional Protocol) (...) are also considered. (shrink)

A growing literature addresses the ethical implications of electronic surveillance at work, frequently assigning ethical priority to values such as the right to privacy. This paper suggests that, in practice, the issues are sociologically more complex than some accounts suggest. This is because many workplace electronic technologies not designed or deployed for surveillance purposes nevertheless embody surveillance capacity. This capacity may not be immediately obvious to participants or lend itself to simple deployment. Moreover, because of their primary functions, such systems (...) embody a range of other features which are potentially beneficial for those utilising them. As a result, more complex ethical dilemmas emerge as different desired goods compete for priority in the decision-making of individuals and groups. From a sociological point of view this raises interesting questions about the way ethical dilemmas arise in the context of the ongoing social relationships of work. The paper explores these issues using data from a study of the development and implementation of a computerised instructional package in a maternity setting. This medical setting illustrates clearly how seeking to assign ethical priority to a particular concern, such as the right to privacy, cannot but oversimplify the real day to day dilemmas encountered by participants. At the same time,the example of the instructional package demonstrates that it is difficult to predict in advance what ethical issues will be raised by technologies that almost always turn out to have a range of capabilities beyond those envisaged in their original design specification. (shrink)

El aborto voluntario del embarazo es un tema de salud global y constituye uno de los más complejos de la bioética, pues tiene connotaciones psicológicas, éticas y jurídicas no solo para la persona que lo practica, sino también para la sociedad donde se desarrolla y para el lugar que en esta ocupa la mujer. Para profundizar en la temática se realizó una revisión bibliográfica para exponer algunos de los dilemas éticos en cuanto a la interrupción del embarazo por malformaciones congénitas. (...) En Cuba en el 2013, se aprobaron las normas para la terminación voluntaria del embarazo, por razones médicas o de salud o por el diagnóstico prenatal de malformaciones congénitas incompatibles con la vida. La conducta ética del asesor genético debe basarse en los principios éticos y bioéticos que se reflejan en los principios de la ética médica, que aplicados al quehacer profesional aseguran y amparan su práctica legal. Abortion is a world health issue and one of bioethics most complex subjects, since it has psychological, ethical and legal connotations not only for the person who experiences it but also for the society where it is carried out and for the role women play in this society. In order to set forth some of the ethical dilemmas regarding abortion due to congenital abnormalities, a bibliographic review meant to deepen on the subject was conducted. Laws for abortion due to medical, health or life incompatible congenital abnormalities prenatal diagnosis were passed in Cuba in 2013. A genetic counselor's ethical behavior must be based on the ethical and bioethical principles reflected on medical ethics principles which, applied to professional work, ensure and protect its legal practice. (shrink)

Most librarians believe that they are part of a profession that is service oriented, democratic and nonjudgmental. Implicit in these principles is a core of professional ethics, allowing librarians to make effective, informed choices in matters affecting the library, its patrons and staff.Many of the ethical dilemmas facing the profession are covered here through a series of case studies. The focus is on librarians' relationships with patrons, colleagues, organizations, resources and vendors. Such issues as parental consent, patrons' rights to (...) privacy, union activities, library endorsements, censorship, and many others are covered. Each case study is followed by questions that highlight the particular ethical problem. (shrink)

Technological advances in veterinary medicine have produced considerable progress in the diagnosis and treatment of numerous diseases in animals. At the same time, veterinarians, veterinary technicians, and owners of animals face increasingly complex situations that raise questions about goals of care and correct or reasonable courses of action. These dilemmas are frequently controversial and can generate conflicts between clients and health care providers. In many ways they resemble the ethical challenges confronted by human medicine and that spawned the creation (...) of clinical ethics committees as a mechanism to analyze, discuss, and resolve disagreements. The staff of the North Carolina State University Veterinary Hospital, a specialty academic teaching institution, wanted to investigate whether similar success could be achieved in the tertiary care veterinary setting. We discuss the background and rationale for this method, as well as the approach that was taken to create a clinical ethics committee. (shrink)

This article proposes and empirically tests a theoretical framework incorporating Reidenbach and Robin’s (J Bus Ethics 10(4):273–284, 1991 ) conceptual model of corporate moral development. The framework is used to examine the relation between governance and business ethics, as proxied by diversity management (DM), and financial reporting quality, as proxied by the magnitude of earnings management (EM). The level of DM and governance quality are measured in accordance with the ratings of Jantzi Research (JR), a leading provider of social and (...) governance research for institutional investors. This DM score is part of an index developed by JR that investment managers use to integrate DM criteria into their investment decisions. As expected, a negative relation between corporate DM development and financial reporting quality is found while controlling for other factors known in the literatures on governance and accounting choices to affect earnings quality. Despite some caveats presented in conclusion, this study contributes to the ethics, governance, and financial reporting literatures by studying the dynamics between governance and ethics in the prevention of EM. (shrink)

The issue of the significance and importance of moral theory to moral reasoning and moral decisions also accompanies ethical discourse between ethics and bioethics, especially in recent decades, as the issue itself is of a theoretical nature. The presence and functionality of moral theory when reasoning in dilemma situations does not only provide the apparatus for decision-making, but even a deeper understanding of responsibility and commitment when anticipating and preventing such situations. Ethics, however, is not a matter of science, but (...) primarily it is a matter of a human view, which in real life must be promoted while dealing with real "human" dilemmas and conflicts. Bioethics education encounters all the pitfalls of current theory and practice, science and ethics. The issues of bioethics are a very topical phenomenon of real life, which has brought about complex issues that man faces and whose solutions have neither theoretical nor empirical parallels with the past. This refers to current and pressing questions that are directly related to life and its intimate sphere. (shrink)

The COVID-19 pandemic has generated an imbalance between the clinical needs of the population and the effective availability of advanced life support (ALS) resources. Triage protocols have thus become necessary. Triage decisions in situations of scarce resources were not extraordinary in the pre-COVID-19 era; these protocols abounded in the context of organ transplantation. However, this prior experience was not considered during the COVID-19 outbreak in Spain. Lacking national guidance or public coordination, each hospital has been forced to put forth (...) independent and autonomous triage protocols, most of which were, nonetheless, based on common ethical principles and clinical criteria. However, controversial, non-clinical criteria have also been defended by Spanish scientific societies and public institutions, including setting an age cut-off value for unilaterally withholding ALS, using ‘social utility’ criteria, prioritising healthcare professionals or using ‘first come, first served’ policies. This paper describes the most common triage criteria used in the Spanish context during the COVID-19 epidemic. We will highlight our missed opportunities by comparing these criteria to those used in organ transplantation protocols. The problems posed by subjective, non-clinical criteria will also be discussed. We hope that this critical review might be of use to countries at earlier stages of the epidemic while we learn from our mistakes. (shrink)

How should driverless vehicles respond to situations of unavoidable personal harm? This paper takes up the case of self-driving cars as a prominent example of algorithmic moral decision-making, an emergent type of morality that is evolving at a high pace in a digitised business world. As its main contribution, it juxtaposes dilemma decision situations relating to ethical crash algorithms for autonomous cars to two edge cases: the case of manually driven cars facing real-life, mundane accidents, on the one (...) hand, and the dilemmatic situation in theoretically constructed trolley cases, on the other. The paper identifies analogies and disanalogies between the three cases with regard to decision makers, decision design, and decision outcomes. The findings are discussed from the angle of three perspectives: aspects where analogies could be found, those where the case of self-driving cars has turned out to lie in between both edge cases, and those where it entirely departs from either edge case. As a main result, the paper argues that manual driving as well as trolley cases are suitable points of reference for the issue of designing ethical crash algorithms only to a limited extent. Instead, a fundamental epistemic and conceptual divergence of dilemma decision situations in the context of self-driving cars and the used edge cases is substantiated. Finally, the areas of specific need for regulation on the road to introducing autonomous cars are pointed out and related thoughts are sketched through the lens of the humanistic paradigm. (shrink)

Background Respect for patients’ autonomy is usually considered to be an important ethical principle in Western countries; privacy is one of the implications of such respect. Healthcare professionals frequently encounter ethical dilemmas during their practice. The past few decades have seen an increased use of courts to resolve intractable ethical dilemmas across both the developed and the developing world. However, Chinese and American bioethics differ largely due to the influence of Chinese Confucianism and Western religions, respectively, and there (...) is a dearth of comparative studies that explore cases of ethical dilemmas between China and the United States. Methods This paper discusses four typical cases with significant social impact. First, it compares two cases concerning patient privacy: the “Shihezi University Hospital Case”, in which a patient was used as a clinical teaching object without her permission, and the “New York-Presbyterian Hospital Case”, in which the hospital allowed the filming of a patient’s treatment without his consent. Second, it compares two cases regarding patient autonomy and potentially life-saving medical procedures: the “Case of Ms. L”, concerning a cohabitant’s refusal to sign a consent form for a pregnant woman’s caesarean, and the “Case of Mrs. V”, concerning a hospital’s insistence upon a blood transfusion for a dissenting patient. This paper introduces the supporting and opposing views for each case and discusses their social impact. It then compares and analyses the differences between China and the United States from cultural and legislative perspectives. Conclusions Ethical dilemmas have often occurred in China due to the late development of bioethics. However, the presence of bioethics earlier in the US than in China has not spared the US of ethical dilemmas. This paper highlights lessons and inspiration from the cases for healthcare professionals and introduces readers to the role and weight of privacy and autonomy in China and in the US from the perspectives of different cultures, religions and laws. (shrink)

How should driverless vehicles respond to situations of unavoidable personal harm? This paper takes up the case of self-driving cars as a prominent example of algorithmic moral decision-making, an emergent type of morality that is evolving at a high pace in a digitised business world. As its main contribution, it juxtaposes dilemma decision situations relating to ethical crash algorithms for autonomous cars to two edge cases: the case of manually driven cars facing real-life, mundane accidents, on the one (...) hand, and the dilemmatic situation in theoretically constructed trolley cases, on the other. The paper identifies analogies and disanalogies between the three cases with regard to decision makers, decision design, and decision outcomes. The findings are discussed from the angle of three perspectives: aspects where analogies could be found, those where the case of self-driving cars has turned out to lie in between both edge cases, and those where it entirely departs from either edge case. As a main result, the paper argues that manual driving as well as trolley cases are suitable points of reference for the issue of designing ethical crash algorithms only to a limited extent. Instead, a fundamental epistemic and conceptual divergence of dilemma decision situations in the context of self-driving cars and the used edge cases is substantiated. Finally, the areas of specific need for regulation on the road to introducing autonomous cars are pointed out and related thoughts are sketched through the lens of the humanistic paradigm. (shrink)

Ethical dilemmas raised by the use of nanotechnology in medical practice can be viewed from several perspectives: religious spiritualist perspective, the perspective of human dignity (nanotechnologies can be thought of as an affront to human dignity), the issue of controversial choice. The article aims to expose some bioethical dilemmas in using synthetic biology and nanotechnologies. Nowadays is often brought into discussion the fact it is possible to appear in the future new human species resulted not via natural (...) selection and evolution, but through the demiurgic effect of technology development in areas such as: synthetic biology, genetics, neurobiology and neurosciences, prosthesis technology and not least of artificial intelligence research. We will also refer into this paper at the possible raised challenges to ethicists who are oriented towards an ethics of species. Those challenges are raised right from the dawn of a consciousness of species, a social construction generated by changes of the meaning of belonging to humanity. During our article we argue that medical technology, especially genetics, medical assisted human reproduction and not least synthetic biology, require a rethinking ethical meanings of applying those technologies in everyday practices. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Incorporating Religion into Psychiatry:Evidenced–Based Practice, Not a Bioethical DilemmaMary D. MollerFor over sixteen years I was the owner and clinical director of an advanced practice nurse–managed outpatient rural psychiatric clinic staffed by APNs, a social worker, a licensed counselor and several graduate students. Many of our patients were victims of severe and often brutal trauma and abuse suffered at the hands of family, friends, and various professionals including (...) spiritual leaders. We also uncovered sources of abuse suffered from those involved in occult practices ranging from seemingly innocent white witchcraft (Wicca, Paganism, New Age) that includes such activities as astral projection and remote viewing to the darkest possible black witchcraft (perpetrating evil, incanting evil spirits, casting spells and hexes, creating dissociative identities) such as occurs in ritual abuse and satanic rites. Both types of witchcraft also typically involved family, friends, various professionals, and spiritual leaders. Recognizing the controversy surrounding the reality of witchcraft I am sharing a story that I hope will help break down the barriers that prevent many patients from receiving the treatment that would provide the most benefit to recovery.Seeking services for these patients led me on an intense personal and professional journey that included a profound Christian born–again experience at almost 50 years of age. My professional career grew in nearly indescribable terms as a result of the incorporation of prayer and deliverance ministry as part of the services we selectively provided. Today I always include assessment of spiritual experiences a patient has as well as spiritual supports that are available with every new patient intake. For patients who indicate that prayer is one of their supports, I ask if they would like prayer at the conclusion of the session. The gratitude that is expressed by individuals who appreciate being able to pray with a psychiatric provider is often profound.In the field of psychiatry there has been a long–standing and distinct taboo regarding incorporating religious and spiritual aspects of life experience into treatment unless it is to frame most of these discussions within the context of psychosis. This stems from the advent of psychoanalysis in which religion was deemed a neurosis and atheism became the goal. Some still hold to that belief and there certainly remains controversy regarding the incorporation of prayer into routine outpatient or inpatient care. The essential starting point is the determination of accurate differential diagnosis, which can often be a lengthy process. The clinician must be careful about distinguishing between religious experiences and religious delusions, and often this takes time to sort out. The determination of the etiology of hearing the voice of God or the devil or demons must be carefully parsed and framed within the context of the situation and culture the patient describes. If the clinician denies the existence of God or the devil or demons or the practice of witchcraft, the patient’s descriptions of such experiences will be quickly [End Page 206] labeled psychotic. The patient may then experience a lengthy hospitalization and treatment with psychotropic medications that can have an extremely negative effect on the possibility of recovery. Once I witnessed the level of healing that occurs with carefully administered spiritual interventions that are related to specific spiritual experiences that are based on the patient’s belief system, there was no going back to using only allopathic medication and non–spiritual psychosocial interventions, even in spite of the criticisms from others. The key is to understand and respect the patient’s belief system, if this is not congruent with the practitioner’s belief system, then practitioner must refer out.In the United States, an increasing persecution of Christianity and a devaluing of the Judeo–Christian heritage of our Constitution are creating a climate of intolerance to the expression of religious values resulting in an expectation that Christians should compromise their beliefs for the sake of political correctness. As a doctorally prepared psychiatric–mental health advanced practice nurse I experienced a profound born–again Christian experience that ultimately led to study of the Hebrew roots of Christianity and I now worship in a Messianic Jewish synagogue. It is impossible for me to not include the concept of spirituality into... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Morality in Flux: Medical Ethics Dilemmas in the People's Republic of ChinaRen-Zong Qiu (bio)IntroductionModern China is undergoing a fundamental change from a monolithic society to a rather pluralistic one. It is a long and winding road. Marxism is facing various challenges as the influence of Western culture increases. Confucianism is still deeply entrenched in the Chinese mind but various religions, including Buddhism, Islam, and Christianity are experiencing a (...) revival. Almost fifty minorities coexist in the country in addition to the majority Han people. Tension and conflict are inevitable as diverse—and sometimes incompatible—values come to the fore at this historic juncture. Many fields, including medicine, face new challenges, and in this environment the field of bioethics is flourishing.Like many countries, China is groping with the effects of new medical technology and skyrocketing health care costs. But in the context of the Chinese sociocultural environment, some unique—as well as more familiar—issues arise. None of the classic texts provide ready-made answers to these dilemmas; we must find the answers ourselves. The only reasonable way to resolve the conflicts between opposing values is through dialogue, consultation, and negotiation among the various social and cultural groups.The bioethical dilemmas receiving the most attention in China now relate to the two ends of life: birth and death. On one end are issues relating to reproductive technology, especially birth control and family planning; at the other end is euthanasia.Dilemmas Surrounding Reproductive TechnologyAccording to traditional Chinese belief, not having a child results from not having virtue. In fact, the most serious violation of the Confucian [End Page 16]principle of filial piety is to be without offspring. A Chinese man without a child experiences heavy psychological pressure, and the burden is especially onerous for women because infertility is always blamed on the wife. Wives who do not bear a child are stigmatized and mistreated—even abused—in families that stick to traditional values.In China today, this widely held belief is colliding with another reality: an apparent increase in infertility among newly-married couples. The rate may be about 5 percent. These couples turn to doctors for help.Artificial insemination by donor (AID) and by husband is now widely practiced. Eleven provinces have established sperm banks, and private doctors are performing AID for considerable fees. But procedures to address legal and ethical problems associated with the procedure have lagged behind. With the exception of a few centers in large cities, AID is undertaken without established procedures or policies relating to the selection of donors and recipients, records about those involved, or clarification of the status of the child. The legal status of the child remains unresolved.The status of the child within the community is also unresolved as traditional values clash with the application of modern technology to childbearing. The case of "The Child Who Did Not Belong" (see box), illustrates how an AID child is not accepted by the family that embraces traditional values because he is not the husband's biological child.In vitro fertilization (IVF) is another alternative. Two IVF centers are in operation, one in Beijing and the other in Changsha, and both have succeeded in producing live births. This technology has received considerable media attention and is generally accepted even among those with traditional views.But much of this medical technology is not widely accessible—especially in rural areas—and so some infertile couples resort to surrogate motherhood to ensure an heir. An infertile couple enters into a contract with a woman who has intercourse with the husband in order to bear a child for the couple. This practice is called "borrowing a wife." In some villages, the "borrowed wife" receives as much as 10,000 yuan (five times a professor's monthly salary or about $250) for a girl and double that for a boy.But the more common and thorny problems involved with the beginning of life relate to birth control, family planning, and the "one couple, one child" policy that the Chinese government instituted to curb overpopulation. The goal of that policy is to prevent China's population from exceeding 1.2 billion in the year 2000... (shrink)

This book examines the many ethical issues that are encountered in the Pediatric Intensive Care Unit. It supports pediatricians, nurses, residents, and other providers in their daily management of critically ill children with the dilemmas that arise. It begins by examining the evolution of pediatric critical care, and who is now impacted by this advancing medical technology. Subsequent chapters explore specific ethical concerns and controversies that are commonly encountered. These topics include how to conduct end-of-life discussions with families (...) facing a myriad of challenging choices. It goes on to explore the concept of futility, and what that does and does not mean in the pediatric ICU setting. Controversial subjects such as children as organ donors, particularly using donation after cardiac death, in addition to issues surrounding the declaration of brain death are covered. Additional chapters address resource allocation, and also analyze the use of long-term technology in chronically critically ill children. Chapters include case examples with guidance on how to work through similar difficulties and decision-making. While this book is specifically targeted for care providers at the ICU bedside, it is also of benefit to medical students, students in bioethics, practicing ethical consultants and families who are dealing with critically ill children. (shrink)

In this volume, written in honour of the eightieth birthday of Professor Shimon Glick, world renowned experts in the field of medical ethics struggle with the question of how to weigh the respective values of autonomy, altruism and authority in dealing with real life bioethical dilemmas.

The ‘family consent’ process has been placed at the centre of Chinese clinical practice. Although there has been critical analysis of how the process functions in relation to the autonomy and rights of patients, there has been little examination of the perceptions and attitude of patients and their families and the medical professionals, in relation to moral dilemmas that arise in real cases in the bioethical discourse. When faced with a consent form in an emergency situation, the (...) family member's capacity to act is reduced, as he/she becomes enmeshed in the hospital structure of tacit, socially-imposed rules. In a questionnaires based on a real death case in 2008, 70.9% of the surveyed medical professionals (n = 3,665) disagreed with performing surgery without the consent of the family even if the patient's life was in danger, while 36.6% of the surveyed patients (n = 1,198) hold the same position. This work demonstrates the weakness of the family consent process as a safeguard of patient's autonomy. Finally, I argue that saving the patient's life should be the overriding obligation rather than the respect for the surrogate's autonomous choice at such a decisive moment. (shrink)

The main message of the paper is that there is a disconnect between what many philosophers of mind think of as the scientific practice of reductive or reductionist explanation, and what the most relevant scientific work is actually like. I will sketch what I see as a better view, drawing on various ideas in recent philosophy of science. I then import these ideas into the philosophy of mind, to see what difference they make.1 At the end of the paper I (...) address a possible objection: the familiar package of ideas I reject in the philosophy of science should not be lightly discarded, because other popular views on fundamental issues depend on positions that I want to reject. I reply that those apparently attractive further ideas are not worth holding onto. (shrink)

In healthcare practice, care providers are confronted with decisions they have to make, directly affecting patients and inevitably harmful. These decisions are tragic by nature. This study investigates the role of Moral Case Deliberation in dealing with tragic situations. In MCD, caregivers reflect on real-life dilemmas, involving a choice between two ethical claims, both resulting in moral damage and harm. One element of the reflection process is making explicit the harm involved in the choice. How harmful are (...) our decisions? We investigated how facilitators of MCD experience the importance of addressing harm in MCD and what participants learn from reflecting on harm. The study was qualitative, focusing on the views and experiences of the facilitators of MCD. Semi-structured interviews were conducted with facilitators of MCD. The research focuses on the subjective experiences of facilitators. Grounded Theory was used for analysis. The results show two main categories. The first concerns the awareness of tragedy. Within this category, five themes were discerned: making explicit that there is no solution, visualizing consequences, uncovering pain, focusing on emotion, and exploring perspectives on harm. The second category concerns the support for healthcare professionals in dealing with the tragedy of the choices they face. In this category, five themes came forward: acknowledging, offering comfort, managing harm, consideration through dialogue and repairing harm. Our study shows that addressing harm in MCD in tragic situations provides an important moral learning opportunity for participants. By formulating and becoming aware of harm, MCD aids healthcare professionals in the task they are faced with, namely making difficult and painful choices. MCD helps healthcare professionals to repair moral damage, making clear at the same time that harm cannot be undone. (shrink)

Movies can serve valuable didactic purposes teaching clinical ethics to medical students. However, using film sequences as means to develop critical thinking is not a straightforward task. There is a significant gap in the literature regarding how to analyse the ethical content embedded in these clips systematically, in a way that facilitates the students’ transition from anecdotal reflections to abstract thinking. This article offers a pedagogical proposal to approach the ethical analysis of film sequences in a systematic fashion. This structured (...) stepwise method encourages students to identify the main ethical problem of a selected scene and to reflect on the theoretical principles involved, emphasizing the application of these norms and values in a contextually situated analysis. We believe this method in film studies both reinforces the students’ comprehension of the theoretical framework of an ethical topic, and casts light on its pertinence and limitations under the circumstances of the scene, thus proving a constructive tool to strengthen the bridge between the theoretical teaching of clinical ethics and clinical practice. (shrink)

Clinical ethicists encounter the most emotionally eviscerating medical cases possible. They struggle to facilitate resolutions founded on good reasoning embedded in compassionate care. This book fills the considerable gap between current texts and the continuing educational needs of those actually facing complex ethics consultations in hospital settings. 28 richly detailed cases explore the ethical reasoning, professional issues, and the emotional aspects of these impossibly difficult consultations. The cases are grouped together by theme to aid teaching, discussion and professional growth. The (...) cases inform any reader who has a keen interest in the choices made in real-life medical dilemmas as well as the emotional cost to those who work to improve the situations. On a more advanced level, this book should be read by ethics committee members who participate in ethics consultations, individual ethics consultants, clinicians who seek education about complex clinical ethics cases, and bioethics students. (shrink)

Newborn infants are among those most severely affected by humanitarian crises. Aid organisations increasingly recognise the necessity to provide for the medical needs of newborns, however, this may generate distinctive ethical questions for those providing humanitarian medical care. Medical ethical approaches to neonatal care familiar in other settings may not be appropriate given the diversity and volatility of humanitarian disasters, and the extreme resource limitations commonly faced by humanitarian aid missions.In this paper, we first systematically review existing guidelines relating to (...) the treatment and resuscitation of newborns in humanitarian crises, finding little substantive ethical guidance for those providing humanitarian healthcare. We next draw on paradigm cases and published literature to identify and describe some of the major ethical questions common to these settings. We divide these questions into quality of life considerations, allocation of limited resources, and conflicting cultural norms and values. We finally suggest some preliminary recommendations to guide ethical decision‐making around resuscitation of newborns and withdrawal of treatment in humanitarian settings. (shrink)

Decision-making capacity in children and adolescents in healthcare requires thorough assessment: the minor's maturity, understanding of the decision, risk of the situation and contextual factors needs to be explored. The intention was to design and validate a test—the Maturtest—to assess the maturity of minors in decision-making processes in healthcare. A reasoning test on moral conflicts for adolescents was designed to infer the degree of maturity of minors applied to decision-making regarding their own health. The test was completed by a sample (...) of 441 adolescents aged from twelve to sixteen, with a corresponding analysis of their psychometric skills to measure feasibility, viability, reliability, validity, and sensitivity to change. Psychometric test results showed viability, reliability, validity, and sensitivity to change. High correlation between the test score and the reference method were notable. A high stability was obtained with an intraclass correlation coefficient. The average response time of the test was twenty-three minutes. This test measures the moral maturity of adolescents. It is presented as an objective, useful, valid, reliable tool, easy to fill out, edit and apply in a healthcare context. It helps to assess the maturity of minors faced with a decision. (shrink)

Two potentially lifesaving protocols, emergency preservation and resuscitation and uncontrolled donation after circulatory determination of death, currently implemented in some U.S. emergency departments, have similar eligibility criteria and initial technical procedures, but critically different goals. Both follow unsuccessful cardiopulmonary resuscitation and induce hypothermia to “buy time”: one in trauma patients suffering cardiac arrest, to enable surgical repair, and the other in patients who unexpectedly die in the ED, to enable organ donation. This article argues that to fulfill patient-focused fiduciary obligations (...) and maintain community trust, institutions implementing both protocols should adopt and publicize policies to guide ED physicians to utilize either protocol for particular patients, in order to address the appearance of conflict of interest arising from the protocols' similarities. It concludes by analyzing ethical implications of incentives that may influence institutions to develop the expertise required for uDCDD but not EPR. (shrink)

Children and adolescents are not indifferent to the dramatic impact of the COVID-19 pandemic, and the need to be forced to live in confinement. The change in life to which they have been abruptly subjected forces us to understand the state of their mental health in order to adequately address both their present and future needs. The present study was carried out with the intention of studying the consequences of confinement on anxiety, sleep routines and executive functioning of 1,028 (...) children and adolescents, aged from 6 to 18 years, residing in Spain to; assess if there are differences regarding these consequences in terms of sex and age; how anxiety affects executive functioning in males and females; and to examine the possible correlations between the measured variables. For this purpose, an online questionnaire containing five sections was designed: the first section gathers information on sociodemographic and health data, while the following sections gather information from different standardized scales which measure anxiety, sleep and executive functions, whose items were adapted in order to be completed by parents, and/or legal guardians. The statistical analyzes carried out highlights significant differences in executive functioning between males and females. In turn, in regards to age, greater difficulties were detected in anxiety in the 9 to 12 age group and greater sleep disturbances between 13 and 18 year olds. On the other hand, significant differences were found in intra-sexual executive functioning depending on whether they presented greater or lesser anxiety, with executive functioning being more tendentiously maladjusted in males than in females, revealing a significantly relevant effect size. Positive correlations are obtained between state anxiety and sleep and executive functioning alterations. Finally, through Path Analysis, it is verified that state anxiety is the variable with the greatest weight within the model that would explain the alteration in the executive functioning of the present sample. (shrink)

Bioethics is the philosophical study of the ethical controversies brought about by advances in biology and medicine. Bioethicists are concerned with the ethical questions that arise in the relationships among life sciences, biotechnology, medicine, politics, law, philosophy, and theology. This book presents research in the expansive field of bioethics including biomedical ethics in obstetrics, ethical decision making in the health care system, the feasibility of using human oocytes for stem cell research, as well as mandatory circumcision in Sub-Saharan Africa (...) to prevent HIV and AIDS and environmental ethics to preserve the world for future generations. (shrink)

Mindful of how the history of bioethics has often been presented, we explore the background, contributions, and influence of Van Rensselaer Potter on the roots of bioethics. In the last few decades, dozens of papers have been written and published, including several doctoral theses and defenses on V. R. Potter‘s concept of bioethics. In those works, the context of the emergence of Potter’s bioethics has sometimes been suggested, but never analyzed thoroughly. We identify seven pillars of influence for Van Rensselaer (...) Potter’s bioethical credo, drawing on several facts from the rich cultural heritage of Wisconsin, where Potter had lived and worked for the most part of his life. (shrink)

In this paper, I argue by example for the possibility of genuine dilemmas internal to Christian ethics. My example is the life of Sebastian Rodrigues, who is the protagonist of Shusaku Endo's moving novel "Silence". The first part of the paper is devoted to retelling Endo's story, highlighting salient ethical and religious features of the life of Rodrigues. The latter half of the paper argues for an interpretation of the story according to which Rodrigues confronts a (...) class='Hi'>real conflict between the obligation to love God with total devotion and the obligation to love one's neighbor as oneself. I conclude with the suggestion that the outcome of this conflict is not ultimately tragic because it serves providentially to move Rodrigues closer to Christ in suffering love. (shrink)

With the rapid development of biotechnology, the physician is now more able to keep a patient's life going indefinitely on a life support system. The question of whether we should switch off the machine often arises when, according to the medical prognosis, there is no hope of recovery, or in a no-win situation where you are 'damned if you do and damned if you don't'. In a case which seems without hope, the dilemma of whether to prolong a (...) life or let it go disturbs many people, including health professionals as well as the family of the patient. In this painful situation, an ethics consultant who has received intensive training can help the concerned parties to arrive at what may be the best decision. How do Asians, especially those living in countries influenced by Confucian teachings, reach their answers? Three aspects are usually considered: (1) motivation and situation; (2) reasonableness and propriety; and (3) lawfulness and legality. More specifically, three questions are deliberated, as follows. (1) Where an action has already been taken, what motivated it and in what situation? Or, where a decision has still to be made, what should motivate it, and what are the relevant features of the situation? (2) Was the attempted resolution of the dilemma, or is its prospective resolution, reasonable and in accordance with traditional principles of ethical behaviour? (3) Was the action taken lawful, or would the intended action be lawful? This approach to finding an answer has been practised for centuries in Confucian society. But what is legal may not always be reasonable, what is reasonable may not always be compassionate, and what is compassionate may not always be either legal or reasonable. Principles to guide decision-making are therefore called for. This article, written by Michael Cheng-tek Tai in collaboration with Donald Hill, discusses the Confucian method of solving a problem and examines its principal features and how they are applied in ethics consultations. The article is followed by a series of questions and answers and a commentary by Donald Hill. (shrink)

PHOTO ID 121339257© Designer491| Dreamstime.com ABSTRACT When physicians use their clinical knowledge and skills to advance the well-being of their patients, there may be apparent conflict between patient autonomy and physician beneficence. We are skeptical that today’s medical ethics education adequately fosters future physicians’ commitment to beneficence, which is both rationally defensible and fundamentally consistent with patient autonomy. We use an ethical dilemma that was presented to a group of third-year medical students to examine how ethics education might be causing (...) them to give undue deference to autonomy, thereby undermining their commitment to beneficence. INTRODUCTION The right of patients to choose which treatments they prefer is rooted in today’s social mores and taught as a principle of medical ethics as respect for autonomy. Yet, when physicians use their clinical knowledge and skills to advance the well-being of their patients, there may be a conflict between patient autonomy and physician beneficence. We are skeptical that today’s medical ethics education adequately fosters a commitment to beneficence, which is both rationally defensible and fundamentally consistent with patient autonomy. I. An Ethical Dilemma The impetus for this paper arose when students who were completing their third clinical year discussed a real-life ethical dilemma. A middle-aged man developed a pulmonary hemorrhage while on blood thinners for a recently placed coronary stent. The bleeding was felt to be reversible, but the patient needed immediate intubation or he would die. The cardiologist was told that the patient previously expressed to other physicians that he never wanted to be intubated. However, the cardiologist made the decision to intubate the patient anyway, and the patient eventually recovered.[1] Students were asked if they believed that the cardiologist had acted ethically. Their overwhelming response was, “No, the patient should have been allowed to die.” We looked into how students applied ethical reasoning to conclude that this outcome was ethically preferred. To explore how the third-year clinical experience might have formed the students’ judgment, we presented the same case to students who were just beginning their third year. Their responses were essentially uniform in recommending intubation. While there is likely more than one reasonable view in this case, we agree with the physician and the younger medical students that intubation was the ethically appropriate decision and will present an argument for it. But first, we explain the reasoning behind the more advanced medical students’ decision to choose patient autonomy at the expense of beneficence. II. Medical Ethics Education and the Priority of Autonomy Beauchamp and Childress’s Principles of Biomedical Ethics, first published in 1979 and now in its 8th edition, is a significant part of the formal ethics education in medical school.[2] Students learn an ethical decision-making approach based on respect for four ethical principles: autonomy, beneficence, nonmaleficence, and justice. While Beauchamp and Childress officially afford no prima facie superiority to any principle, the importance of respect for patient autonomy has increased through the editions of their book. For example, early editions of their book opposed the legalization of physician-assisted death compared to recent editions that defended it.[3] As another example, Beauchamp and Childress make paternalism harder to justify by adding an autonomy-protecting condition to the list of conditions for acceptable paternalism.[4] Authority, they contend, need not conflict with autonomy—provided the authority is autonomously chosen.[5] “The main requirement,” they write, “is to respect a particular patient’s or subject’s autonomous choices, whatever they may be.[6] In the principlism of Beauchamp and Childress, autonomy now seems to have a kind of default priority.[7] However, the bioethics discourse has strong counternarratives, noting some movement to elevate the role of beneficence and to respect the input of stakeholders, including the family and the healthcare team. Ethics education achieves particular relevance in the third clinical year when students become embedded in the care of patients and learn from what has been called the informal curriculum. They observe how attending physicians approach day-to-day ethical problems at the patient’s bedside. In this context, students observe the importance of informed consent for serious treatments or invasive procedures, a practice that highlights the principle of patient autonomy. In both the formal and informal curriculum, medical students observe how, in the words of Paul Wolpe, “patient autonomy has become the central and most powerful principle in ethical decision-making in American medicine.”[8] In short, students appear to learn a deference for patient autonomy. This curricular shift in favor of autonomy coincides with legal developments that protect patients’ rights and decision-making with respect to their healthcare choices. The priority of autonomy in medicine benefits patients by reflecting their choices and, in some cases, their fundamental liberty. III. The Practice of Medicine and the Commitment to Beneficence There are many critiques of the dominant place that autonomy has in biomedical ethics,[9] especially considering that autonomy seems to be biased toward individualistic, Western, and somewhat American culture-driven values.[10] In addition, many bioethical dilemmas are cast as a conflict between autonomy and beneficence. Our point is that medical students bring to their study of medicine a commitment to beneficence that seems to be suppressed by practical ethics education. We think this commitment is rationally defensible and should be nurtured. It is striking that young medical students have a pre-reflective commitment to beneficence at all. For, as we mentioned, it is not just medicine but Western culture generally that prioritizes autonomy in settling ethical dilemmas. In wanting to act for the good of others (rather than simply agreeing to what others want), physicians are already swimming somewhat against the cultural tide.[11] However, doing so makes sense, given the nature of medicine and the profession of healing. When prospective medical students are asked why they wish to become physicians, the usual answer is some variation on caring for the sick and preventing disease. It is unlikely that a reason to become a physician is to respect a patient’s autonomy. It would be easy to dismiss medical students’ commitment to beneficence as a mere intuition and contrary to a more reasoned and deliberative approach. Beauchamp and Childress seem to minimize the value of physician intuition, stating that justifications for certain procedures are “…supported by good reasons. They need not rest merely in intuition or feeling.”[12] Henry Richardson writes that “situational or perceptive intuition…leaves the reasons for decision unarticulated.”[13] We think this is a crude and rather thin way of understanding intuition. Some bioethicists have defended intuition as essential to the practice of medicine and not something opposed to reason.[14] In the case we describe, we believe the ethical justifications s for the patient’s intubation are fundamentally sound: the patient did not have a “do not intubate” order written in the chart, the emergency intubation had not been foreseen, so the patient did not have the opportunity to consent to or reject intubation; the patient had consented to the treatment for his cardiac disease so his consent for intubation could have been assumed;[15] and the consequences of respecting his autonomy did not justify allowing him to die.[16] While it is possible to have more than one reasonable view on this case, we think the case for beneficence is strong and certainly should not be dismissed out of hand. We do not deny that if a patient makes a clearly documented, well-informed decision to forgo intubation that this decision ought to be respected by the physician (even if the physician disagrees with the patient’s decision). But, in this situation, as in many others in the practice of medicine, the patient’s real wishes and preferences are not well-articulated in advance. There are many cases where a physician acts based on what she believes the patient, or the surrogate, would want, sometimes in situations that do not allow much time for reflection. An example might be resuscitation of a newborn at the borderline of viability. In their ethics education, beneficence would mean acting first to save a life. If the patient or surrogate makes an informed decision to the contrary, a beneficent physician respects that autonomous decision. In the case presented, the patient expressed gratitude to the cardiologist when extubated. But what if he had expressed anger at the physician for violating his autonomy? There are those who could argue that not only was intubation ethically wrong but that the cardiologist put himself in legal jeopardy by his actions (especially if there had been a written refusal applicable to the specific situation). In the example we use, we point out that the cardiologist may not have escaped a lawsuit if the patient had died without intubation. His family, when hearing the circumstances, may have sued for failure to act and dereliction of the cardiologist’s duty to save him. Beyond a potential legal challenge for either action or inaction, there is an overriding ethical question the cardiologist had to address: what course would be most satisfying to his conscience? Would he rather allow a patient to die for fear of recrimination, or act to save his life, regardless of the personal consequences? In the absence of real knowledge about the patient’s considered wishes, it is most reasonable to err on the side of promoting patient well-being. A physician’s commitment to beneficence is not necessarily a way of undermining a patient’s autonomy. In acting for the patient's good, physicians are also acting on what it is reasonable to believe a patient (or most patients, perhaps) would want, which is obviously connected to what a patient does want. Pellegrino and Thomasma argue that beneficence includes respect for a patient’s autonomy since “the best interests of the patient are intimately linked with their preferences.”[17] Instead of conceptualizing ethical dilemmas in medicine as conflicts between autonomy and beneficence, it is possible that medical schools could teach students that truly practicing beneficence is a way of valuing patient autonomy, especially when the patient’s wishes are not specific to the situation and are not clearly expressed. CONCLUSION It is important for students and practicing physicians to understand the principle of respect for patient autonomy in a pluralistic society that demands personal self-determination. However, the role of the physician as a beneficent healer should not be diminished by this respect for autonomy. Respecting a patient’s autonomy is grounded in and manifested by physician beneficence.[18] That is, seeking what is good for the patient can only be good if it respects their personhood and dignity. We propose that a commitment to beneficence, incipient in young medical students, should be developed over time with their other clinical reasoning skills. Such a commitment need not be sacrificed on the altar of patient autonomy. Beneficence needs greater relative moral weight with students as they proceed in their ethics education. - [1] S. Jauhar, “When Doctors Need to Lie,” New York Times, February 22, 2014, https://www.nytimes.com/2014/02/23/opinion/sunday/when-doctors-need-to-lie.html. [2] T. L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 8th ed. (New York, NY: Oxford University Press, 2019). [3] Louise A. Mitchell, “Major Changes in Principles of Biomedical Ethics,” The National Catholic Bioethics Quarterly 14, no. 3 (2014): 459–75, https://doi.org/10.5840/ncbq20141438. [4] Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 8th ed. (New York, NY: Oxford University Press, 2019), 238. [5] Beauchamp and Childress, 103. [6] Beauchamp and Childress, p. 108. [7] For other accounts that prioritize autonomy, see e.g. Allen E. Buchanan and Dan W. Brock, Deciding for Others: The Ethics of Surrogate Decision Making (Cambridge University Press, 1989), 38–39; R Gillon, “Ethics Needs Principles—Four Can Encompass the Rest—and Respect for Autonomy Should Be ‘First among Equals,’” Journal of Medical Ethics 29, no. 5 (October 2003): 307–12, https://doi.org/10.1136/jme.29.5.307. For examples of critiques of these accounts, see footnote 9. [8] P. R. Wolpe, “The Triumph of Autonomy in American Bioethics: A Sociological View,” in Bioethics and Society: Constructing the Ethical Enterprise, p. 43. [9] V. A. Entwistle et al., “Supporting Patient Autonomy: The Importance of Clinician-Patient Relationships,” Journal of General Internal Medicine 25, no. 7 (July 2010): 741–45; C. Foster, Choosing Life, Choosing Death: The Tyranny of Autonomy in Medical Ethics and Law, 1st ed. (Oxford ; Hart Publishing, 2009); O. O’Neill, Autonomy and Trust in Bioethics, The Gifford Lectures, University of Edinburgh 2001 (Cambridge, UK: Cambridge University Press, 2002). [10] P. Marshall and B. Koenig, “Accounting for Culture in a Globalized Bioethics,” The Journal of Law, Medicine & Ethics: A Journal of the American Society of Law, Medicine & Ethics 32, no. 2 (2004): 252–66; R. Fan, “Self-Determination vs. Family-Determination: Two Incommensurable Principles of Autonomy,” Bioethics 11, no. 3–4 (1997): 309–22. [11] Arguments stressing the importance of beneficence, as ours does here, certainly approach paternalistic arguments. We set aside the complex issue of paternalism for purposes of this paper and simply note that the principle of beneficence as such does not say anything specifically about acting against the patient’s will. In the case study that focuses this paper, we do not believe the patient’s will or wishes were clearly indicated. [12] Beauchamp and Childress, Principles of Biomedical Ethics, p. 20, see note 2 above. [13] H. S. Richardson, “Specifying, Balancing, and Interpreting Bioethical Principles,” The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine 25, no. 3 (January 1, 2000): 285–307, p. 287. [14] H. D. Braude, Intuition in Medicine a Philosophical Defense of Clinical Reasoning (Chicago ; University of Chicago Press, 2012). [15] R. Kukla, “Conscientious Autonomy: Displacing Decisions in Health Care,” The Hastings Center Report 35, no. 2 (2005): 34–44. [16] M. Schermer, The Different Faces of Autonomy: Patient Autonomy in Ethical Theory and Hospital Practice, vol. 13, Library of Ethics and Applied Philosophy (Dordrecht: Springer Netherlands, 2002). [17] E. D. Pellegrino and D. C. Thomasma, For the Patient’s Good - the Restoration of Beneficence in Health Care (New York, NY: Oxford University Press, 1988), p. 29. [18] Pellegrino and Thomasma, For the Patient’s Good. 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