Ethics consultation at the bedside has been hailed as a better way than courts and ethics committees to empower patients and make explicit the value components of treatment decisions. But close examination of the practice of ethics consultation reveals that it in fact risks subverting those ends by interpolating a third (expert) party into the doctor-patient encounter. In addition, the practice of bioethics through consultation does the broader cultural work of fashioning a shared moral order in the face of manifestly (...) plural individual commitments. In doing so, however, bioethics furthers medicine's position as a privileged domain of public moral discourse in contemporary American society. (shrink)

Anne Barnhill focuses her article in this issue on the American Medical Association's ethics policy governing clinical use of placebos, but the implications of her analysis are deeper, touching on how physicians should make judgments about which interventions to offer patients in the process of shared decision‐making. The bottom line is that, even if an undisclosed placebo might be marginally more effective for a particular patient in the short term, over the long haul the integrity of the patient‐physician relationship relies (...) on doctors being honest with their patients. Even when it comes to placebos, honesty remains the best policy. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Conflicts—and Consensus—about Conflicts of Interest in MedicineMatthew K. Wynia and Bette–Jane Crigger*This fascinating collection of essays about individual experiences of conflict of interest leaves little doubt that physicians remain divided about the importance, impact and meaning of conflicts of interest in their work. These essays offer differing views about what conflicts of interest look and feel like “on the ground” and about whether specific conflicts of (...) interest are bad, just a fact of life, or maybe even good.Conflict, Conflict EverywhereThese essays situate conflict of interest in a variety of contexts: the treatment recommendations a physician makes for an individual patient; the relationship between teaching physician and medical student or practicing physician and health care organization; the interaction between academic researchers and industry collaborators or professional bodies and industry supporters. In this, the narratives taken together reflect the scope of concern about conflict of interest in medicine familiar in the literature. In his classic 1993 essay, Dennis Thompson noted that concerns about conflict of interest encompass issues of physician self–referral, risk sharing between physicians and health care institutions, gifts from industry, hospital purchasing practices, as well as sponsored research and research with patients (Thompson 1993). To that list have subsequently been added relationships with industry in medical education at all levels, physicians’ service as consultants to industry or members of industry speakers bureau, and development of clinical practice guidelines (Lo & Fields 2009).That almost none of these essays draw attention to some widely publicized situations of conflict of interest—for example, gifts to physicians or the provision of drug samples—should, we think, be seen more as an artifact of the authors’ varied individual experiences than as a failure by the authors to engage key concerns in the ongoing professional and public debate. It could also be that the authors, asked to submit personal stories, assumed that yet another essay about the ‘traditional’ issues in the conflicts of interest literature would be seen as redundant, routine or even boring. Or, there is the tantalizing possibility that the absence of some of the more familiar conflicts from these narratives is the early fruit of efforts to address these traditional issues through policies governing interactions between physicians and industry promulgated by academic medical centers and health systems, medical specialty societies, and industry.One significant area of concern that has emerged in recent years is conflict of interest in the development of clinical practice guidelines. E.g., Choudry et al. 2002; Sniderrman & Furberg 2009; Guyatt et al. 2010. Although none of the essays in this [End Page 101] collection address it head on, Perlmutter touches on several key issues. His depiction of how an FDA committee process limited the input he was able to provide as an expert, undermined his potential to contribute to the professional dialogue, and raised concerns about the objectivity of the drug approval process echoes concerns about objectivity, the role of expert opinion, and the presence on guideline development panels of individuals with financial interests in the recommendations to be developed that have been explored at some length in the literature, most recently by the Institute of Medicine in reports on evidentiary standards (Eden et al 2011) and principles for guideline development (Graham et al. 2011).Conflict of Interest or Dual Agency?Several essays set out physicians’ experience in navigating situations of diverging expectations. Bierut, for example, reflects on the disjunction between the goals and products of academic researchers and commercial sponsors. She saw herself advancing basic knowledge and was forced to grapple with the reality of sponsors’ goals to advance commercial ends as well. Nagldinne and Mikulec each recall struggles to reconcile their obligation to exercise professional judgment on behalf of patients with the demands of health care organizations focussed also on the bottom line. Cruz–Flores attests to the challenge of making recommendations for care when one is both a practicing clinician and a clinical investigator engaged in research that might offer benefit to a patient for whom there are limited options.Thompson defined conflicts of interest as “a set of conditions in which professional judgment concerning a primary interest (such as a patient’s welfare or the validity of... (shrink)

Although many physicians have been using the internet for both clinical and social purposes for years, recently concerns have been raised regarding blurred boundaries of the profession as a whole. In both the news media and medical literature, physicians have noted there are unanswered questions in these areas, and that professional self-regulation is needed. This report discusses the ethical implications of physicians’ nonclinical use of the internet, including the use of social networking sites, blogs, and other means to post content (...) online. It does not address the clinical use of the internet, such as telemedicine, e-prescribing, online clinical consultations, health-related websites, use of electronic media for clinical collaboration, and e-mailing patients (some of which are already covered in the AMA’s Code of Medical Ethics). (shrink)

Beginning Bioethics introduces students to the language of philosophical ethics before leading them in Part Two through six major issues in bioethics. The author gives clear explanations of all sides of a given issue and engages with several major contributions to the debate. This book can stand alone, but was written also to accompany the third edition of Bette-Jane Crigger's Cases in Bioethics, providing the philosophical counterpart to cases discussed there by US medical practitioners. Both books originate (...) with St Martin's Press in the United States. (shrink)

Access to communication is critical for individuals with late-stage amyotrophic lateral sclerosis and minimal volitional movement, but they sometimes present with concomitant visual or ocular motility impairments that affect their performance with eye tracking or visual brain-computer interface systems. In this study, we explored the use of modified eye tracking and steady state visual evoked potential BCI, in combination with the Shuffle Speller typing interface, for this population. Two participants with late-stage ALS, visual impairments, and minimal volitional movement completed a (...) single-case experimental research design comparing copy-spelling performance with three different typing systems: commercially available eye tracking communication software, Shuffle Speller with modified eye tracking, and Shuffle Speller with SSVEP BCI. Participant 1 was unable to type any correct characters with the commercial system, but achieved accuracies of up to 50% with Shuffle Speller eye tracking and 89% with Shuffle Speller BCI. Participant 2 also had higher maximum accuracies with Shuffle Speller, typing with up to 63% accuracy with eye tracking and 100% accuracy with BCI. However, participants’ typing accuracy for both Shuffle Speller conditions was highly variable, particularly in the BCI condition. Both the Shuffle Speller interface and SSVEP BCI input show promise for improving typing performance for people with late-stage ALS. Further development of innovative BCI systems for this population is needed. (shrink)

Nurses make mistakes in practice despite the culturally based expectation of perfection. Such a disparity between reality and expectation calls members of the profession to question the current attitudes toward mistakes in practice. Two explanatory models of the origin of mistakes are presented. The Perfectibility Model holds that any error or harm is caused by an individual practitioner's lack of knowledge or motivation. The Faulty Systems Model offers a broader explanation of human error. I conclude that a Faulty Systems Model (...) is more comprehensive and more effective for managing mistakes. Integrating the Faulty Systems Model into practice and education can result in more ethically fitting responses to errors and ultimately better outcomes for nurses, institutions and patients. (shrink)

The study was prompted by (a) Frederick and Vogel's debate concerning future research in business and society, (b) such recently reported managerial excesses as golden parachutes, greenmail, and fraud, (c) the increasing emphasis on coursework in the area. It appears that there is a need to assess how students, our future business leaders, perceive social issues and if a business and society course can help them define and understand the importance of these issues.Three questions provided the focal point: (1) Which (...) issues do students perceive as most important before and after completing the course? (2) How much importance do students place on issues? (3) Does completing a business and society course make a significant difference in how students perceive the importance of the issues presented? (shrink)

Augmentative and alternative communication brain-computer interface systems are intended to offer communication access to people with severe speech and physical impairment without requiring volitional movement. As the field moves toward clinical implementation of AAC-BCI systems, research involving participants with SSPI is essential. Research has demonstrated variability in AAC-BCI system performance across users, and mixed results for comparisons of performance for users with and without disabilities. The aims of this systematic review were to describe study, system, and participant characteristics reported in (...) BCI research, summarize the communication task performance of participants with disabilities using AAC-BCI systems, and explore any differences in performance for participants with and without disabilities. Electronic databases were searched in May, 2018, and March, 2021, identifying 6065 records, of which 73 met inclusion criteria. Non-experimental study designs were common and sample sizes were typically small, with approximately half of studies involving five or fewer participants with disabilities. There was considerable variability in participant characteristics, and in how those characteristics were reported. Over 60% of studies reported an average selection accuracy ≤70% for participants with disabilities in at least one tested condition. However, some studies excluded participants who did not reach a specific system performance criterion, and others did not state whether any participants were excluded based on performance. Twenty-nine studies included participants both with and without disabilities, but few reported statistical analyses comparing performance between the two groups. Results suggest that AAC-BCI systems show promise for supporting communication for people with SSPI, but they remain ineffective for some individuals. The lack of standards in reporting outcome measures makes it difficult to synthesize data across studies. Further research is needed to demonstrate efficacy of AAC-BCI systems for people who experience SSPI of varying etiologies and severity levels, and these individuals should be included in system design and testing. Consensus in terminology and consistent participant, protocol, and performance description will facilitate the exploration of user and system characteristics that positively or negatively affect AAC-BCI use, and support innovations that will make this technology more useful to a broader group of people.Clinical trial registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42018095345, PROSPERO: CRD42018095345. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Creating a Learning Space That Is Virtual and ExperientialBette E. Schneiderman (bio)The final product of the Rembrandt Project will be a Web site that is intended primarily for use by middle and high school teachers and their students. It is a celebration of Rembrandt’s work in the contexts of his time, place, and culture and all that may emanate from them. A special feature of the site is the (...) integration of art, aesthetic, and social studies education. Other articles in this issue address the rich content of the project’s work, that is, the artworks themselves, their contextual grounding, and the development of skills that maximize learning. This article looks at the creation of a learning space as a home for the development of the project. It explores issues related to learning spaces and features some of the technologies that can be used within them.The Rembrandt Project will not be a Web site that merely flattens images on a computer screen or conveys facts about Rembrandt and his oeuvre. Rather, it is a portal to a learning place with online features and opportunities for learners to have transformative experiences. Learning may occur online in electronic conversations, in opportunities to view and respond to reproductions in collections that cannot be visited in person, and in the creation and display of learners’ products. Learning is facilitated by access to a range of resources and people. Numerous announcements of activities, events, and products will be posted on the site. Some individuals will work in the space of the works themselves while others might undertake learning activities in museums, galleries, and private homes. In some cases special programs will highlight certain works and relate them to the project. Images of places in the Netherlands will also be presented with accompanying learning opportunities for those who may wish to see the paintings in person or simply ponder their influence from afar. All participants will be encouraged to share creations and reflections on the site. [End Page 38]To provide a sense of what this article is about, three cases are presented, each with two scenarios and a sample online discussion. The purpose of these cases is to draw readers into the experience of a virtual learning space before discussing contemporary learning communities, learning spaces, and technologies. The cases will show how to develop lively democratic conversation that makes communal learning possible. Participants can be of all kinds, from experts to those who simply want to learn. They can be located anywhere and participate at whatever time suits them best.Case A: Two ScenariosScenario 1: Viewing a Masterwork by RembrandtStanding before a work by Rembrandt you are drawn into its space. If you have viewed a Rembrandt in the past, recall your experience. If not, perhaps you might want to travel to a place that has one of his works or access some of his images online.1 Or you might think about a work of art that aroused your interest and prompted you to ponder its import and ask questions. Perhaps you returned to the work many times, experiencing it more deeply and differently upon each visit. What is it, specifically, about the encounter that resulted in a satisfying experience? And what changed the moment you viewed the work in a book reproduction, a slide, or a digitized image on a computer? In pursuing its purposes, the Rembrandt Project explores ways multiple skills can help maximize the experience of a wide range of works both online and off. Case A, Scenario 1, will set the stage for an experience with the work itself.Scenario 2: Viewing a Masterwork OnlineSelect a major work by Rembrandt online.2 What makes experiencing this image worthwhile, despite the fact that certain aspects cannot be captured in this flat digitized space? Upon reflecting on these scenarios, thoughts about experiencing the work may be recorded and discussed with others.3Case B: Two ScenariosScenario 1: An Experience of a LandscapeImagine wandering through an open field, tingled by a gentle breeze, warmed by the sun, refreshed by the aromas of moist grasses, mixed flowers, and the woody smells of trees. A village, visible... (shrink)

This article reviews the incredible growth of electronic commerce (e-commerce) and presents ethical issues that have emerged. Security concerns, spamming, Web sites that do not carry an "advertising" label, cybersquatters, online marketing to children, conflicts of interest, manufacturers competing with intermediaries online, and "dinosaurs" are discussed. The power of the Internet to spotlight issues is noted as a significant force in providing a kind of self-regulation that supports an ethical e-commerce environment.

This article reviews the incredible growth of electronic commerce (e-commerce) and presents ethical issues that have emerged. Security concerns, spamming, Web sites that do not carry an "advertising" label, cybersquatters, online marketing to children, conflicts of interest, manufacturers competing with intermediaries online, and "dinosaurs" are discussed. The power of the Internet to spotlight issues is noted as a significant force in providing a kind of self-regulation that supports an ethical e-commerce environment.

The new science of genomics endeavors to chart the genomes of individuals around the world, with the dual goals of understanding the role genetic factors play in human health and solving problems of disease and disability. From the perspective of indigenous peoples and developing countries, the promises and perils of genomic science appear against a backdrop of global health disparity and political vulnerability. These conditions pose a dilemma for many communities when attempting to decide about participating in genomic research or (...) any other biomedical research. Genomic research offers the possibility of improved technologies for managing the acute and chronic diseases that plague their members. Yet, the history of particularly biomedical research among people in indigenous and developing nations offers salient examples of unethical practice, misuse of data, and failed promises. This dilemma creates risks for communities who decide either to participate or not to participate in genomic science research. Some argue that the history of poor scientific practice justifies refusal to join genomic research projects. Others argue that disease poses such great threats to the well-being of people in indigenous communities and developing nations that not participating in genomic research risks irrevocable harm. Thus, some communities particularly among indigenous peoples have declined to participate as subjects in genomic research. At the same time, some communities have begun developing new guidelines, procedures, and practices for engaging with the scientific community that offer opportunities to bridge the gap between genomic science and indigenous and/or developing communities. Four new approaches warrant special attention and further support: consulting with local communities; negotiating the complexities of consent; training members of local communities in science and health care; and training scientists to work with indigenous communities. Implicit is a new definition of “rigorous scientific research,” one that includes both community development and scientific progress as legitimate objectives of genomic research. Innovative translational research is needed to develop practical, mutually acceptable methods for crossing the divide between genomic researchers and indigenous communities. This may mean the difference between success and failure in genomic science, and in improving health for all peoples. (shrink)

The new science of genomics endeavors to chart the genomes of individuals around the world, with the dual goals of understanding the role genetic factors play in human health and solving problems of disease and disability. From the perspective of indigenous peoples and developing countries, the promises and perils of genomic science appear against a backdrop of global health disparity and political vulnerability. These conditions pose a dilemma for many communities when attempting to decide about participating in genomic research or (...) any other biomedical research. Genomic research offers the possibility of improved technologies for managing the acute and chronic diseases that plague their members. Yet, the history of biomedical research among people in indigenous and developing nations offers salient examples of unethical practice, misuse of data and failed promises. This dilemma creates risks for communities who decide either to participate or not to participate in genomic science research. (shrink)

When discussing the problem of evil, philosophers often distinguish between physical evil (harm caused within the natural world such as natural disasters, disease, and the like), and moral evil (harm caused by human agency). Mapping this traditional distinction is mapped onto the third section of Fichte’s The Vocation of Man would at first seem fairly straightforward: for Fichte, evil arising from nature occurs through “blind mechanism” and is unfree; in contrast, evil done by human beings arises out of free agency. (...) The answer may be more complicated, however, in two different ways. First, Fichte holds that nature is to be cultivated and controlled by human beings so that it is no longer a source of harm; this may imply that the continuing harm done by nature is the result of humans’ failure to have sufficiently tamed nature. In that case, some of the harm caused by nature may be attributable to free human causality and thus no longer be a clearcut instance of natural evil. Second, Fichte repeatedly states that those who fail to act morally and who fail to conform their wills to the moral law are still be in the power of the mechanisms of nature. Even though we must think of them as free, Fichte compares their actions to the operation of nature and its mechanism of necessity. By presenting a careful and nuanced Fichtean account of the traditional distinction between physical and moral evil, we can better appreciate how Fichte understood the meaning and scope of human responsibility. (shrink)

Human Progress is often understood to be a rather natural and obvious truth of human existence. That this is not necessarily so, is indicative of the pervasive social, psychological, and educational inculcation that sustains its ubiquitous acceptance. Moreover, the uncritical and ill‐informed understanding of Progress as an unquestioned expression of human beneficence has serious consequences for those concerned with the health and welfare of people. It is argued in this paper that, much of what we might consider deleterious in the (...) socio‐political milieu that now confronts us is, to a significant extent, a matter of progressive ideological epistemology and its ensuing manner of human institutionalization. Part one contends that the current socio‐political structure of the current postmodern affairs is in reality that of a pervasive postmodern economic ideology. Part two provides a brief overview of the historical and philosophical development of Progress as an idea, including some of the profound effects wrought by it on human affairs in the contemporary world. Finally, Part three presents a discussion of the influential effects of the philosophy of Progress on the epistemology of human health and welfare intervention, specifically that of nursing and its claim to a holistic ethic of Caring. (shrink)