: The "difference position" holds that clinical research and therapeutic medical practice are sufficiently distinct activities to require different ethical rules and principles. The "similarity position" holds instead that clinical investigators ought to be bound by the same fundamental principles that govern therapeutic medicine—specifically, a duty to provide the optimal therapeutic benefit to each patient or subject. Some defenders of the similarity position defend it because of the overlap between the role of attending physician and the role of investigator in (...) a research trial. This overlap is maximal when the same physician occupies both roles with respect to a particular patient-subject. We address the ethical tensions inherent in that role conflict and argue that the tensions are real but manageable. The difference position provides a sound ethical framework within which to manage those tensions, while the similarity position is unsatisfactory because it seeks to deny the existence of the tensions. (shrink)

Some ethical issues facing contemporary medicine cannot be fully understood without addressing medicine's internal morality. Medicine as a profession is characterized by certain moral goals and morally acceptable means for achieving those goals. The list of appropriate goals and means allows some medical actions to be classified as clear violations of the internal morality, and others as borderline or controversial cases. Replies are available for common objections, including the superfluity of internal morality for ethical analysis, the argument that internal morality (...) is merely an apology for medicine's traditional power and authority, and the claim that there is no single, "core" internal morality. The value of addressing the internal morality of medicine may be illustrated by a detailed investigation of ethical issues posed by managed care. Managed care poses some fundamental challenges for medicine's internal morality, but also calls for thoughtful reflection and reconsideration of some traditionally held moral views on patient fidelity in particular. (shrink)

A special report of The Hastings Center and the Association of American Medical Colleges addressed the ethical oversight of learning health systems, which seek to combine high‐quality patient care with routine data collection aimed at improving patient outcomes. The report contained two position papers, authored by a number of distinguished bioethicists, and several commentaries. The position papers urged two changes. First, they urged a rethinking of our approach to the regulation of human subjects research, so as to make it easier (...) in the future for learning health systems to function well. Second, they argued that the rethinking required dispensing with a strict distinction between research and therapy, which has been a major tenet of bioethics since the Belmont Report, which explicated basic ethical principles governing human subjects research. We fully support the objectives of the authors, and we agree that the learning health system is an important advance that serves patients well. Unnecessary regulatory burden ought not impede this progress. We disagree, however, that the best way to bring about these needed changes in the regulatory environment is to reject the basic distinction between research and treatment. Unfortunately, we find the arguments in favor of that strategy to be, in places, reminiscent of what we take to be basic conceptual errors that hampered the ethical understanding of human subjects research prior to adoption of the Belmont Report. To see why one need not reject the research‐treatment distinction in order to promote learning health systems, we first investigate in some detail the arguments offered for eliminating the distinction. We next turn to an issue not addressed by those authors, namely, the relationship between the physician or investigator and the patient or subject, to illustrate why the distinction is important and what is lost if it is jettisoned. (shrink)

A predominant ethical view holds that physician‐investigators should conduct their research with therapeutic intent. And since a physician offering a therapy wouldn't prescribe second‐rate treatments, the experimental intervention and the best proven therapy should appear equally effective. "Clinical equipoise" is necessary. But this perspective is flawed. The ethics of research and of therapy are fundamentally different, and clinical equipoise should be abandoned.

The leading ethical position on placebo-controlled clinical trials is that whenever proven effective treatment exists for a given condition, it is unethical to test a new treatment for that condition against placebo. Invoking the principle of clinical equipoise, opponents of placebo-controlled trials in the face of proven effective treatment argue that they (1) violate the therapeutic obligation of physicians to offer optimal medical care and (2) lack both scientific and clinical merit. We contend that both of these arguments are mistaken. (...) Clinical equipoise provides erroneous ethical guidance in the case of placebo-controlled trials, because it ignores the ethically relevant distinction between clinical trials and treatment in the context of clinical medicine and the methodological limitations of active-controlled trials. Placebo controls are ethically justifiable when they are supported by sound methodological considerations and their use does not expose research participants to excessive risks of harm. (shrink)

A basic question of medical ethics is whether the norms governing medical practice should be understood as the application of principles and rules of the common morality to medicine or whether some of these norms are internal or proper to medicine. In this article we describe and defend an evolutionary perspective on the internal morality of medicine that is defined in terms of the goals of clinical medicine and a set of duties that constrain medical practice in pursuit of these (...) goals. This perspective is developed by means of a critical examination of the essentialist conception of the internal morality of medicine advocated by Edmund Pellegrino and the critique of internal morality approaches by Robert Veatch and Tom Beauchamp. (shrink)

Cosmetic surgery is a fast-growing medical practice. In 1997 surgeons in the United States performed the four most common cosmetic procedures443,728 times, an increase of 150% over the comparable total for 1992. Estimated total expenditures for cosmetic surgery range from $1 to $2 billion. As managed care cuts into physicians' income and autonomy, cosmetic surgery, which is not covered by health insurance, offers a financially attractive medical specialty.

The practice of voluntary physician‐assisted death as a last resort is compatible with doctors' duties to practice competently, to avoid harming patients unduly, to refrain from medical fraud, and to preserve patients' trust. It therefore does not violate physicians' professional integrity.

The doctrine of clinical equipoise is appealing because it appears to permit physicians to maintain their therapeutic obligation to offer optimal medical care to patients while conducting randomized controlled trials (RCTs). The appearance, however, is deceptive. In this article we argue that clinical equipoise is defective and incoherent in multiple ways. First, it conflates the sound methodological principle that RCTs should begin with an honest null hypothesis with the questionable ethical norm that participants in these trials should never be randomized (...) to an intervention known to be inferior to standard treatment. Second, the claim that RCTs preserve the therapeutic obligation of physicians misrepresents the patient-centered orientation of medical care. Third, the appeal to clinical equipoise as a basic principle of risk-benefit assessment for RCTs is incoherent. Finally, the difficulties with clinical equipoise cannot be resolved by viewing it as a presumptive principle subject to exceptions. In the final sections of the article, we elaborate on the non-exploitation framework for the ethics clinical research and indicate issues that warrant further inquiry. (shrink)

With breathtalung speed, traditional criminal prohibitions against assisted suicide have been declared unconstitutional in twelve states, including California and New York. This poses great promise and great peril. The promise is that competent terminally ill patients, as a compassionate measure of last resort, will have the option of putting an end to their suffering by physician-assisted suicide. More sigmficant, legally permitting this controversial option may be a catalyst for doctors, health care institutions, and society to improve the care of the (...) dying. PAS should be limited only to those relatively few competent patients who continue to suffer intolerably despite unrestrained efforts to palliate and who face a continued existence that they regard as worse than death. When dying patients know they will not be abandoned to miserable and pointless suffering if palliative care fails, they will be fortified to cope better with the process of dying.The immediate peril is that PAS will become a quick fix, available on demand to any patient diagnosed as terminally ill, thus bypassing palliative care and producing premature deaths. (shrink)

"Unlike most photographs of Eads Bridge, which are taken from a distance, Quinta Scott's intimate photographic essay shows the subtleties of form and texture that give this structure its remarkable aesthetic impact. Howard Miller's text complements the photos, explaining the place of James Eads's unorthodox design in the history of American architecture and aesthetics. Miller also explains the bridge's place in local and national economic history, describes its innovative engineering, and brings to life its unique creator."--Jacket.

*The opinions expressed are the views of the author and do not necessarily reflect the policy of the National Institutes of Health, the Public Health Service, or the U.S. Department of Health and Human Services.

Realism in international relations theory is frequently understood to entail the abandonment or cynical manipulation of moral rules and principles. But realism has always been more than an amoral or immoral doctrine. More interesting versions of realism offer moral justifications for limiting the role of morality. We argue for a version of realism that flows from the function of the liberal democratic state as an indispensable condition of value. After setting out its central characteristics, we also argue that this liberal (...) democratic realism can adequately address four severe criticisms typically raised against realism in general. (shrink)

We are drowning in information, while starving for wisdom.Are the smartest people also the wisest? Not necessarily. While traditional intellectual reasoning and procedural knowledge have helped build the communities we live in, there is a growing scientific understanding that we need emotionally balanced and better-fitting prosocial frameworks for coping with the uncertainties and complexities of life and addressing new challenges of the modern world. We are now poised on the edge of a new science of wisdom.The concept of wisdom, long (...) considered the “pinnacle of insight into the human condition”, has been that of an intangible, subjective, culturally specific entity—an unscientific... (shrink)

CHAPTER I POLITICAL FAITH AND UTOPIAN THOUGHT In the three and a half centuries since Bacon and the miller prayed for peace among the willows, countless men ...

Like Henry Harris, I began doing intensive research on Hegel's Phenomenology of Spirit in the mid-sixties. I recall going through all the chapters as a graduate student during one academic year, and looking around for commentaries. The only English-language commentary available was Loewenberg's Hegel's Phenomenology: Dialogues in the Life of Mind, which was suggestive of the dialectic taking place in the book, but not much help in getting over the “rough spots”. This gave me an incentive to work through Jean (...) Hyppolite's commentary, not yet translated into English, with my basic reading-knowledge of French. My 1976 Hegel's Phenomenology, Part I: Analysis and Commentary was one of the first in a long line of Anglophone commentaries. Harris in his introduction to Vol. I. mentions this effort at “analysis”, along with Findlay's “analysis” accompanying the 1977 Miller translation of the Phenomenology, as incentives for the inclusion of his own improved running analysis in the present commentary. I have included discussions of numerous partial or complete commentaries on Hegel's Phenomenology in review articles published in 1971 in the American Philosophical Quarterly and Teorema, in 1979 in the American Philosophical Quarterly, and in 1981 in Hegel-Studien. Harris has the advantage of producing the most recent of all these commentaries, and in a way offers us a compendium of everything that has been done on the Phenomenology. His analysis and commentary includes a survey of the literature, in which almost all previous laborers in the field can find themselves commended or criticized in the endnotes. Thus I find comments like “Kainz has completely misunderstood the argument here”, “This is a point which Kainz has grasped more definitely than most commentators”, “[Kainz] does not deserve the brickbat Flay hurls at him”, and so forth. Other commentators, living and dead – Flay, Pöggeler, Navickas, Kenneth and Merold Westphal, Heidegger, Lauer, Werner Becker, Kojève, Wahl, Hyppolite, Labarrière, Bonsiepen, Forster, Shklar, Solomon, Werner Marx, and Robert Williams — are similarly discussed and critiqued. For some of us Anglophone commentators, such remarks may seem like red marks on essays from a patient professor. But certainly no one will mind, since Harris has spent more time and energy on this very specialized project than any of us. In fact, some former commentators almost have a “conflict of interest” in reviewing Harris' work, since so many of us have benefited at various points in our research from Harris' personal support and criticism. But in academics, as in life, mentors cannot always be assured of loyalty. (shrink)

In The Healer's Power, Howard Brody placed the concept of power at the heart of medicine's moral discourse. Struck by the absence of “power” in the prevailing vocabulary of medical ethics, yet aware of peripheral allusions to power in the writings of some medical ethicists, he intuited the importance of power from the silence surrounding it. He formulated the problem of the healer's power and its responsible use as “the central ethical problem in medicine.” Through the prism of power (...) he refracted a wide range of ethical problems, from informed consent to truth-telling, from confidentiality to futility, from the physician's fantasies to the physician's virtues. At times this prism shed new light on old problems, enabling us to see from an unexpected angle the elements of which the problem was composed. At other times it exposed issues of ethical significance that had been neglected in the bioethics literature. (shrink)

A letter to the editor from Howard Brody, David Buchanan, and Franklin G. Miller in response to the recent article by Erik Malmqvist Understanding Exploitation," March-April 2011).

After critiquing some earlier attempts (including those of Marcus Singer and Frances Howard–Snyder) to ground objections to actual–consequence act utilitarianism (ACAU) on human cognitive limitations, I present two new objections with this same foundation. Both start with the observation that, because human cognitive abilities are not up to the task of reliably recognizing utility–maximizing actions, any agents who are recognizably human – including the best possible humans, morally speaking – are certain to perform many actions every day that ACAU (...) says are immoral, and to perform some actions over the course of their lives that it says are highly immoral. The first objection is that, if Mill's analysis of what it means to call an action wrong is accurate, then ACAU entails a conclusion that no one will accept, viz., that the morally–best humans possible ought to undergo constant punishment. The second objection is that ACAU entails that even the morally–best humans possible are bad moral agents in some respect. This conclusion, while unpalatable, is not so obviously unacceptable as the first. However, I do briefly consider some ways in which it might be possible to demonstrate that it is false and thereby complete a reductio of ACAU. (shrink)

Like Henry Harris, I began doing intensive research on Hegel's Phenomenology of Spirit in the mid-sixties. I recall going through all the chapters as a graduate student during one academic year, and looking around for commentaries. The only English-language commentary available was Loewenberg's Hegel's Phenomenology: Dialogues in the Life of Mind, which was suggestive of the dialectic taking place in the book, but not much help in getting over the “rough spots”. This gave me an incentive to work through Jean (...) Hyppolite's commentary, not yet translated into English, with my basic reading-knowledge of French. My 1976 Hegel's Phenomenology, Part I: Analysis and Commentary was one of the first in a long line of Anglophone commentaries. Harris in his introduction to Vol. I. mentions this effort at “analysis”, along with Findlay's “analysis” accompanying the 1977 Miller translation of the Phenomenology, as incentives for the inclusion of his own improved running analysis in the present commentary. I have included discussions of numerous partial or complete commentaries on Hegel's Phenomenology in review articles published in 1971 in the American Philosophical Quarterly and Teorema, in 1979 in the American Philosophical Quarterly, and in 1981 in Hegel-Studien. Harris has the advantage of producing the most recent of all these commentaries, and in a way offers us a compendium of everything that has been done on the Phenomenology. His analysis and commentary includes a survey of the literature, in which almost all previous laborers in the field can find themselves commended or criticized in the endnotes. Thus I find comments like “Kainz has completely misunderstood the argument here”, “This is a point which Kainz has grasped more definitely than most commentators”, “[Kainz] does not deserve the brickbat Flay hurls at him”, and so forth. Other commentators, living and dead – Flay, Pöggeler, Navickas, Kenneth and Merold Westphal, Heidegger, Lauer, Werner Becker, Kojève, Wahl, Hyppolite, Labarrière, Bonsiepen, Forster, Shklar, Solomon, Werner Marx, and Robert Williams — are similarly discussed and critiqued. For some of us Anglophone commentators, such remarks may seem like red marks on essays from a patient professor. But certainly no one will mind, since Harris has spent more time and energy on this very specialized project than any of us. In fact, some former commentators almost have a “conflict of interest” in reviewing Harris' work, since so many of us have benefited at various points in our research from Harris' personal support and criticism. But in academics, as in life, mentors cannot always be assured of loyalty. (shrink)

In challenging the prevailing paradigm for understanding how the human mind works, Patterns, Thinking, and Cognition is certain to stimulate fruitful debate.

In this paper, I argue that a commitment to a very modest form of egalitarianism—equality between non-disabled human adults—implies fetal personhood. Since the most plausible bases for human value are in being human, or in a gradated property, and since the latter of which implies an inequality between non-disabled adult humans, I conclude that the most plausible basis for human equality is in being human—an attribute which fetuses have.

In this article, I undertake three main tasks. First, I argue that, contrary to the standard view, moral injury is not a species of PTSD (post-traumatic stress disorder) but rather, on the most coherent conception of moral injury, PTSD is (in effect) a species of moral injury. In doing so, I make use of the notion of caring deeply about something or someone worthy of being cared deeply about. Second, I consider so-called “dirty hands” actions in police work and in (...) war, and distinguish these from the morally legitimate, but harmful, actions of police officers and of war fighters, such as the morally legitimate use of coercive force and lethal force (respectively). While the morally legitimate use of harmful methods is constitutive of these occupational roles, “dirty hands” methods are not. Roughly speaking, a “dirty hands” action is one that is morally wrong and (typically) unlawful but done for the sake of a good outcome. Both categories of action are conducive to moral injury, but “dirty hands” actions much more so, especially given the slippery moral slope from “dirty hands” actions to egregious moral wrongdoing. Third, I offer some recommendations for reducing moral injury among police officers and war fighters. (shrink)

Most accounts of why physicians have a duty to treat patients during a pandemic look to the special ethical standards of the medical profession. An adequate account must be deeper and broader: it must set the professional duty alongside other individual commitments and broader social values.

Current legal standards of informed consent send the wrong message to physicians about their moral and legal expectations. A “transparency” model that sees consent as a conversation process can enhance good medical practice and patient autonomy without foreclosing appropriate judicial review.

Bioethics' interdisciplinary base -- Patient-centered care -- Evidence-based medicine and pay-for-performance -- Community dialogue -- Overview : bioethics, power, and learning to see -- Cross-cultural concerns -- Race and health disparities -- Disabilities -- Environmental and global issues -- New technologies -- Conclusion.

In 1987, a young woman named Angela Carder, pregnant and dying from cancer, was ordered by a court of law to undergo a cesarean delivery against her and her family’s wishes. She and her baby both died. Three years later, an appeals court took an extraordinary stand: it vacated the order that ended their lives and upheld pregnant women’s rights to informed consent and bodily integrity. The “unkindest cut of all,”1 it seemed, had been condemned by the courts.2 Yet shortly (...) before the twenty-year anniversary of this landmark case, the same rights were stripped from another young pregnant woman. In January of this year, oral arguments were heard in the case of Samantha Burton. She had been twenty-five weeks .. (shrink)

Philosophical attention to animals can be found in a wide range of texts throughout the history of philosophy, including discussions of animal classification in Aristotle and Ibn Bâjja, of animal rationality in Porphyry, Chrysippus, Aquinas and Kant, of mental continuity and the nature of the mental in Dharmakīrti, Telesio, Conway, Descartes, Cavendish, and Voltaire, of animal self-consciousness in Ibn Sina, of understanding what others think and feel in Zhuangzi, of animal emotion in Śāntarakṣita and Bentham, and of human cultural uniqueness (...) in Xunzi. In recent years, there has been increased attention to animal minds in philosophical discussions across many areas of metaphysics, epistemology, and value theory. Given that nonhuman animals share some biological and psychological features with humans, and that we share community, land, and other resources, consideration of nonhuman animals has much to contribute to our philosophical activities. -/- Contemporary philosophy of animal minds often also engages with the sciences of animal cognition and behavior. The science of comparative cognition is a thriving area of research, complementing the philosophical study in two ways. For one, philosophers of animal cognition can use claims resulting from animal cognition studies as premises in philosophical discussions. For example, Jacob Beck (2012) relies on pigeons’ abilities to compare quantities to argue for nonconceptual content; Sidney Carls-Diamante (forthcoming) appeals to octopus behavior and physiology to defend embodied cognition; Richard Moore (2016a) refers to ape gestural communication to rethink the requirements for intentional communication; Andrew Barron and Colin Klein (2016) appeal to insect cognition research to defend new theories of consciousness; Sarah Vincent, Rebecca Ring, and Kristin Andrews (2019) cite dolphins’ social practices to argue for the existence of norms that do not require metacognition. -/- In addition, philosophers of animal cognition can examine the epistemology and methods used to justify the claims that arise from the science. Research into animal cognition has resulted in surprising claims about animal capacities, such as sociality in garter snakes (Skinner & Miller 2020), tool-use in ants (Maák et al. 2017), mirror self-recognition in fish (Kohda et al. 2019), empathy in rats (Bartal et al. 2011), social learning in fruit flies (Danchin et al. 2018), episodic memory in dogs (Fugazza et al. 2020), addition and subtraction in bees (Howard et al. 2019). How should we evaluate such claims? -/- Some philosophers have argued that animal cognition research is held to a higher standard than human cognition research, and that scientists working with animals are sometimes asked to solve skeptical problems (Halina 2015). Others have challenged scientific assumptions about the relationship between brain size and intelligence, as well as biases against invertebrates (Mikhalevich & Powell 2020). -/- Animal cognition research challenges philosophers to consider that many capacities and behaviors often assumed to require language, sophisticated technological capacities, or legal systems may in fact be had by other animals who lack these properties. In this way, animal cognition research often surprises us by showing that sophisticated-looking activity can be caused through rather simple mechanisms. -/- 1. What is Animal Cognition? 2. Philosophical Assumptions in the Study of Animal Cognition 2.1 Theory-ladenness 2.2 Value-ladenness 2.3 Objectivity 2.4 Simplicity 2.5 Summary 3. Animal Cognition Applied to Philosophy 3.1 The problem of other minds 3.2 The mind-body problem 3.3 Consciousness 3.4 Thought 3.5 Communication 3.6 Social understanding 3.7 The influence of animal cognition on value theory 3.7.1 Ethics 3.7.2 Political theory 3.8 Summary Bibliography Academic Tools Other Internet Resources Related Entries. (shrink)