The best things in my Ufe have come to me by accident and this book results from one such accident: my having the opportunity, out of the blue, to go to work as H. Tristram Engelhardt, Jr. 's, research assistant at the Institute for the Medical Humanities in the University of Texas Medi cal Branch at Galveston, Texas, in 1974, on the recommendation of our teacher at the University of Texas at Austin, Irwin C. Lieb. During that summer Tris "lent" (...) me to Chester Bums, who has done important schol arly work over the years on the history of medical ethics. I was just finding out what bioethics was and Chester sent me to the rare book room of the Medical Branch Library to do some work on something called "medical deontology. " I discovered that this new field of bioethics had a history. This string of accidents continued, in 1975, when Warren Reich took Tris Engelhardt's word for it that I could write on the history of modem medical ethics for Warren's major new project, the Encyclopedia of Bioethics. Warren then asked me to write on eighteenth-century British medical ethics. (shrink)
The clinical application of the concept of patient autonomy has centered on the ability to deliberate and make treatment decisions (decisional autonomy) to the virtual exclusion of the capacity to execute the treatment plan (executive autonomy). However, the one-component concept of autonomy is problematic in the context of multiple chronic conditions. Adherence to complex treatments commonly breaks down when patients have functional, educational, and cognitive barriers that impair their capacity to plan, sequence, and carry out tasks associated with chronic care. (...) The purpose of this article is to call for a two-component re-conceptualization of autonomy and to argue that the clinical assessment of capacity for patients with chronic conditions should be expanded to include both autonomous decision-making and autonomous execution of the agreed-upon treatment plan. We explain how the concept of autonomy should be expanded to include both decisional and executive autonomy, describe the biopsychosocial correlates of the two-component concept of autonomy, and recommend diagnostic and treatment strategies to support patients with deficits in executive autonomy. (shrink)
The clinical ethics literature is striking for the absence of an important genre of scholarship that is common to the literature of clinical medicine: systematic reviews. As a consequence, the field of clinical ethics lacks the internal, corrective effect of review articles that are designed to reduce potential bias. This article inaugurates a new section of the annual "Clinical Ethics" issue of the Journal of Medicine and Philosophy on systematic reviews. Using recently articulated standards for argument-based normative ethics, we provide (...) a systematic review of the literature on concealed medication for the management of psychiatric disorders. Four steps are completed: identify a focused question; conduct a literature search using key terms relevant to the focused question; assess the adequacy of the argument-based methods of the papers identified; and identify conclusions drawn in each paper and whether they apply to the focused question. We identified seven papers and provide an assessment of them. While none of the papers fully meet the standards of argument-based ethics, they did provide rationales for the use of concealed medications, with the important requirement such a practice be accountable in explicit organizational policy to prevent abuse of patients with mental illness or dementia. (shrink)
Research to improve the health of pregnant and fetal patients presents ethical challenges to clinical investigators, institutional review boards, funding agencies, and data safety and monitoring boards. The Common Rule sets out requirements that such research must satisfy but no ethical framework to guide their application. We provide such an ethical framework, based on the ethical concept of the fetus as a patient. We offer criteria for innovation and for Phase I and II and then for Phase III clinical trials (...) to improve the health of pregnant patients and of fetal patients and also criteria to responsibly manage the transition from investigation to clinical practice. Basing ethical criteria for research involving pregnant women on the ethical concept of the fetus as a patient insulates the proposed ethical framework and therefore research on pregnant women from the divisive and politicized concepts and discourses of personhood, fetal rights, and unborn child. (shrink)
On February 3, 2010, a “Letter of Concern from Bioethicists,” organized by fetaldex.org, was sent to report suspected violations of the ethics of human subjects research in the off-label use of dexamethasone during pregnancy by Dr. Maria New. Copies of this letter were submitted to the FDA Office of Pediatric Therapeutics, the Department of Health and Human Services (DHHS) Office for Human Research Protections, and three universities where Dr. New has held or holds appointments. We provide a critical appraisal of (...) the Letter of Concern and show that it makes false claims, misrepresents scientific publications and websites, fails to meet standards of evidence-based reasoning, makes undocumented claims, treats as settled matters what are, instead, ongoing controversies, offers “mere opinion” as a substitute for argument, and makes contradictory claims. The Letter of Concern is a case study in unethical transgressive bioethics. We call on fetaldex.org to withdraw the letter and for co-signatories to withdraw their approval of it. (shrink)
Moral distress is one of the core topics of clinical ethics. Although there is a large and growing empirical literature on the psychological aspects of moral distress, scholars, and empirical investigators of moral distress have recently called for greater conceptual clarity. To meet this recognized need, we provide a philosophical taxonomy of the categories of what we call ethically significant moral distress: the judgment that one is not able, to differing degrees, to act on one’s moral knowledge about what one (...) ought to do. We begin by unpacking the philosophical components of Andrew Jameton’s original formulation from his landmark 1984 work and identify two key respects in which that formulation remains unclear: the origins of moral knowledge and impediments to acting on that moral knowledge. We then selectively review subsequent literature that shows that there is more than one concept of moral distress and that explores the origin of the values implicated in moral distress and impediments to acting on those values. This review sets the stage for identifying the elements of a philosophical taxonomy of ethically significant moral distress. The taxonomy uses these elements to create six categories of ethically significant moral distress: challenges to, threats to, and violations of professional integrity; and challenges to, threats to, and violations of individual integrity. We close with suggestions about how the proposed philosophical taxonomy of ethically significant moral distress sheds light on the concepts of moral residue and crescendo effect of moral distress and how the proposed taxonomy might usefully guide prevention of and future qualitative and quantitative empirical research on ethically significant moral distress. (shrink)
Despite its prominence in the abortion debate and in public policy, the discourse of 'unborn patient' has not been subjected to critical scrutiny. We provide a critical analysis in three steps. First, we distinguish between the descriptive and normative meanings of 'unborn child.' There is a long history of the descriptive use of 'unborn child.' Second, we argue that the concept of an unborn child has normative content but that this content does not do the work that opponents of abortion (...) want it to do, namely, to establish the independent moral status of fetuses and their rights, the right to life in particular. Third, we argue that the normative content of 'unborn child' should be dependent moral status, not independent moral status. We conclude that the ethical concept of the fetus as a patient should replace the discourse of “unborn child” when that phrase is used normatively. (shrink)
Physicians make some medical decisions without disclosure to their patients. Nondisclosure is possible because these are silent decisions to refrain from screening, diagnostic or therapeutic interventions. Nondisclosure is ethically permissible when the usual presumption that the patient should be involved in decisions is defeated by considerations of clinical utility or patient emotional and physical well-being. Some silent decisions - not all - are ethically justified by this standard. Justified silent decisions are typically dependent on the physician's professional judgment, experience and (...) knowledge, and are not likely to be changed by patient preferences. We condemn the inappropriate exclusion of the patient from the decision-making process. However, if a test or treatment is unlikely to yield a net benefit, disclosure and discussion are at times unnecessary. Appropriate silent decisions are ethically justified by such considerations as patient benefit or economy of time. (shrink)
Bioethics has a founding story in which medical paternalism, the interference with the autonomy of patients for their own clinical benefit, was an accepted ethical norm in the history of Western medical ethics and was widespread in clinical practice until bioethics changed the ethical norms and practice of medicine. In this paper I show that the founding story of bioethics misreads major texts in the history of Western medical ethics. I also show that a major source for empirical claims about (...) the widespread practice of medical paternalism has been misread. I then show that that bioethics based on its founding story deprofessionalizes medical ethics. The result leaves the sick exposed to the predatory power of medical practitioners and healthcare organizations with only their autonomy-based rights to non-interference, expressed in contracts, to protect them. The sick are stripped of the protection afforded by a professional, fiduciary relationship of physicians to their patients. Bioethics based on its founding story reverts to the older model of a contractual relationship between the sick and medical practitioners not worthy of intellectual or moral trust (because such trust cannot be generated by what I call ‘deprofessionalizing bioethics’). On closer examination, bioethics based on its founding story, ironically, eliminates paternalism as a moral category in bioethics, thus causing bioethics to collapse on itself because it denies one of the necessary conditions for medical paternalism. Bioethics based on its founding story should be abandoned. (shrink)
Philosophy textbooks typically treat bioethics as a form of "applied ethics"-i.e., an attempt to apply a moral theory, like utilitarianism, to controversial ethical issues in biology and medicine. Historians, however, can find virtually no cases in which applied philosophical moral theory influenced ethical practice in biology or medicine. In light of the absence of historical evidence, the authors of this paper advance an alternative model of the historical relationship between philosophical ethics and medical ethics, the appropriation model. They offer two (...) historical case studies to illustrate the ways in which physicians have "appropriated" concepts and theory fragments from philosophers, and demonstrate how appropriated moral philosophy profoundly influenced the way medical morality was conceived and practiced. (shrink)
Rosamond Rhodes makes a persuasive case for the view that medical ethics does not derive from common morality.1 Rhodes identifies the challenge that immediately arises and its corollary: Whence the origin of medical ethics? And, should we understand medical ethics as autonomous? From the perspective of professional ethics in medicine, the first question can now be restated: Whence the origin of the ethical concept of medicine as a profession, the basis of the ethical obligations of physicians in patient care, research, (...) medical education, and in advocacy and healthcare policy? The history of Western philosophy offers us two pathways to address this question. The first is the quest for certainty,2 a quest fulfilled by using methods designed to discover concepts that are independent of human thought and judgement and thus intellectually and morally authoritative for everyone. Such concepts are timeless and therefore transcultural, transreligious and transnational. Examples include Plato’s Forms,3 PF Stawson’s ‘our conceptual structure’,4 Edmund Pellegrino’s ‘fact of illness’ and the ‘act of profession’ in response to the vulnerability that illness creates,5 and common morality.6 Thought experiments, using what Rhodes characterises as ‘the hypethetico-deductive method’,1 aim to discover timeless concepts. Discovering timeless concepts must address their ontological and epistemological status. Plato’s ontology of Forms,2 for example, is not clear, as …. (shrink)
The Cambridge World History of Medical Ethics is the first comprehensive scholarly account of the global history of medical ethics. Offering original interpretations of the field by leading bioethicists and historians of medicine, it will serve as the essential point of departure for future scholarship in the field. The volumes reconceptualize the history of medical ethics through the creation of new categories, including the life cycle; discourses of religion, philosophy, and bioethics; and the relationship between medical ethics and the state, (...) which includes a historical reexamination of the ethics of apartheid, colonialism, communism, health policy, imperialism, militarism, Nazi medicine, Nazi "medical ethics," and research ethics. Also included are the first global chronology of persons and texts; the first concise biographies of major figures in medical ethics; and the first comprehensive bibliography of the history of medical ethics. An extensive index guides readers to topics, texts, and proper names. (shrink)
In this issue of Perspectives in Biology and Medicine, Schneiderman and colleagues critique a recent multi-society policy statement—developed by the American Thoracic Society and endorsed by four other organizations—entitled “Responding to Requests for Potentially Inappropriate Treatment in Intensive Care Units”. The focus of Schneiderman’s critique is the Multiorganization Policy Statement’s choice of the term “potentially inappropriate” to describe a class of interventions that clinicians should resist providing for patients near the end of life, even when patients or their families request (...) or demand them.1 Schneiderman and colleagues argue that the term... (shrink)
This essay presents complementarity as a novel feature of bioethical pluralism. First introduced by Neils Bohr in conjunction with quantum physics, complementarity in bioethics occurs when different perspectives account for equally important features of a situation but are mutually exclusive. Unlike conventional approaches to bioethical pluralism, which attempt in one fashion or another to isolate and choose between different perspectives, complementarity accepts all perspectives. As a result, complementarity results in a state of holistic, dynamic tension, rather than one that yields (...) singular or final moral judgments. (shrink)
THIS PAPER IS A COMMENTARY ON LUDWIK FLECK'S ESSAY ON THE CONNECTION BETWEEN WHAT HE CALLS "THOUGHT-STYLES" AND SCIENTIFIC AND MEDICAL CONCEPTS. THE IDEA OF A "THOUGHT-STYLE" APPLIED TO CONCEPTS OF DISEASE IS THAT THEY ARE NOT ONLY VALUE-LADEN IN THE SENSE OF INCLUDING NORMATIVE DIMENSIONS. THEY ALSO EMBRACE BROAD SOCIAL FACTORS, AS WELL. I ARGUE THAT THOUGHT-STYLES SHOULD BE UNDERSTOOD TO BE "OPEN-TEXTURED," ADMITTING A PLURALITY OF VALUE CONSIDERATIONS TO CONCEPTS OF DISEASE.
The concept of medicine as a profession in the English-language literature of medical ethics is of recent vintage, invented by the Scottish physician and medical ethicist, John Gregory (1724-1773). Gregory wrote the first secular, philosophical, clinical, and feminine medical ethics and bioethics in the English language and did so on the basis of Hume's principle of sympathy. This paper provides a brief account of Gregory's invention and the role that Humean sympathy plays in that invention, with reference to key texts (...) in Gregory's work. The paper also considers two interesting and perhaps provocative ways in which Hume can be read through Gregory: first, sympathy as a principle of scientific discovery in Hume's science of man and moral physiology; and sympathy as gendered feminine in Hume's moral philosophy. Hume's principle of sympathy is at the core of Gregory's medical ethics and the histories of Western medical ethics and bioethics pivot on Gregory - and, therefore, on Hume - as it does on few other figures. (shrink)
Some problems that arise in the account given by Thomasma and Pellegrino [6] of the foundations of medical ethics in a philosophy of medicine are addressed, in particular questions of a conceptual character about treating therelatum of medicine as health. Which concept of health is appropriate and which will bear the burden of the position thomasma and Pellegrino advance? It is argued that the proper relationship of medicine is one between a healer and developing embodied minds. As a consequence, the (...) project of providing a univocal account of the nature of medicine fails. Instead, pluralism infects philosophy and medicine, resulting in different philosophies of medicine. From these philosophies of medicine will follow not a single medical ethics but a variety. (shrink)
On February 3, 2010, a “Letter of Concern from Bioethicists,” organized by fetaldex.org, was sent to report suspected violations of the ethics of human subjects research in the off-label use of dexamethasone during pregnancy by Dr. Maria New. Copies of this letter were submitted to the FDA Office of Pediatric Therapeutics, the Department of Health and Human Services Office for Human Research Protections, and three universities where Dr. New has held or holds appointments. We provide a critical appraisal of the (...) Letter of Concern and show that it makes false claims, misrepresents scientific publications and websites, fails to meet standards of evidence-based reasoning, makes undocumented claims, treats as settled matters what are, instead, ongoing controversies, offers “mere opinion” as a substitute for argument, and makes contradictory claims. The Letter of Concern is a case study in unethical transgressive bioethics. We call on fetaldex.org to withdraw the letter and for co-signatories to withdraw their approval of it. (shrink)
The daily work of the clinical ethics teacher and clinical ethics consultant falls into the routine of classifying clinical cases by ethical type and proposing ethically justified alternatives for the professionally responsible management of a specific type of case. Settling too far into this routine creates the risk of philosophical inertia, which is not good either for the clinical ethicist or for the field of clinical ethics. The antidote to this philosophical inertia and resultant blinkered vision of clinical ethics is (...) sustained, willing exposure to philosophical provocation. The papers in this clinical ethics issue of the Journal of Medicine and Philosophy provide just such philosophical provocation related to core topics in clinical ethics: the distinction between clinical practice and clinical research; telemedicine, or medicine at a distance; illness narratives; the concept of the placebo effect; and sex reassignment. (shrink)
(2001). The History of Medical Ethics Is Crucial for a Critical Perspective in the Continuing Development of Ethics Consultation. The American Journal of Bioethics: Vol. 1, No. 4, pp. 55-57.
Managed care employs two business tools of managed practice that raise important ethical issues: paying physicians in ways that impose conflicts of interest on them; and regulating physicians' clinical judgment, decision making, and behavior. The literature on the clinical ethics of managed care has begun to develop rapidly in the past several years. Professional organizations of physicians have made important contributions to this literature. The statements on ethical issues in managed care of four such organizations are considered here, the American (...) Medical Association, the American College of Physicians, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics. Three themes common to these statements are identified and critically assessed: the primacy of meeting the medical needs of each individual patient; disclosure of conflicts of interest in how physicians are paid; and opposition to gag orders. The paper concludes with an argument for a basic concept in the clinical ethics of managed care: physicians and institutions as economically disciplined moral co-fiduciaries of populations of patients. (shrink)
Despite its prominence in the abortion debate and in public policy, the discourse of ‘unborn patient’ has not been subjected to critical scrutiny. We provide a critical analysis in three steps. First, we distinguish between the descriptive and normative meanings of ‘unborn child.’ There is a long history of the descriptive use of ‘unborn child.’ Second, we argue that the concept of an unborn child has normative content but that this content does not do the work that opponents of abortion (...) want it to do, namely, to establish the independent moral status of fetuses and their rights, the right to life in particular. Third, we argue that the normative content of ‘unborn child’ should be dependent moral status, not independent moral status. We conclude that the ethical concept of the fetus as a patient should replace the discourse of “unborn child” when that phrase is used normatively. (shrink)
Taking the critical turn is one of the main tools of the humanities and inculcates an intellectual discipline that prevents ossification of thinking about issues and of organizational policies in clinical ethics. The articles in this "Clinical Ethics" number of the Journal take the critical turn with respect to cherished ways of thinking in Western clinical ethics, life extension, the clinical determination of death, physicians' duty to treat even at personal risk, clinical ethics at the interface of research ethics, and (...) the pertinence of the Hippocratic Oath to clinical ethics. These articles challenge clinical ethicists to inculcate the intellectual discipline of the critical turn into everyday practice and continuous quality enhancement of clinical ethics. (shrink)
The pluralism of methodologies and severe time constraints pose important challenges to pedagogy in clinical ethics. We designed a step-by-step student handbook to operate within such constraints and to respect the methodological pluralism of bioethics and clinical ethics. The handbook comprises six steps: Step 1: What are the facts of the case?; Step 2: What are your obligations to your patient?; Step 3: What are your obligations to third parties to your relationship with the patient?; Step 4: Do your obligations (...) converge or conflict?; Step 5: What is the strongest objection that could be made to the identification of convergence in step 4 or the arguments in step 4? How can this objection be effectively countered?; and Step 6: How could the ethical conflict, or perceived ethical conflict, have been prevented? (shrink)
The first textbook on the subject, this is a practical, clinically comprehensive guide to ethical issues in surgical practice, research, and education written by some of the most prominent figures in the fields of surgery and bioethics. Discussions of informed consent, confidentiality, and advance directives--core concepts integral to every surgeon-patient relationship--open the volume. Seven chapters tackle the ethical issues in surgical practice, covering the full range of surgical patients--from emergency, acute, high-risk, and elective patients, to poor surgical risk and dying (...) patients. The book even considers the special relationship between the surgeon and patients who are family members or friends. Chapters on surgical research and education address innovation, self-regulation in practice and research, and the prevention of unwarranted bias. Two chapters focus on the multidisciplinary nature of surgery, including the relationships between surgery and other medical specialties and the obligations of the surgeon to other members of the surgical team. The economic dimensions of surgery, especially within managed care, are addressed in chapters on the surgeons financial relationships with patients, conflicts of interest, and relationships with payers and institutions. The authors do not engage in abstract discussions of ethical theory; instead, their discussions are always directly relevant to the everyday concerns of practicing surgeons. This well-integrated volume is intended for practicing surgeons, medical educators, surgical residents, bioethicists, and medical students. (shrink)
Moral concerns about the authority, power, and trustworthiness of physicians have become important topics in clinical ethics during the past three decades. These concerns have come to greater prominence with the increasing involvement of large-scale private institutions in the organization and delivery of medical services, especially managed care organizations, and with the increasing involvement of government in the payment for and organization and delivery of medical services. When physicians act as the agents of large institutions or governments, the power of (...) physicians over their patients increases. The purposes of this article are (1) to reflect briefly on the historical origins of the moral problem of physicians' power in medicine, and (2) to introduce the articles in the 1999 annual number of the Journal of Medicine and Philosophy on topics in clinical ethics. (shrink)
