Aim: To assess, against a checklist of specific areas of required information and using standard published criteria, to what extent leaflets given before cataract surgery provided patients with enough information to give adequately informed consent.Method: Twelve ophthalmology departments in the West Midlands region were asked to submit the cataract information leaflets given to their patients at the preoperative assessment for analysis. Using criteria published by the General Medical Council, British Medical Association, and Medical Defence Union (...) the leaflets were assessed for their contribution to informed consent for patients considering cataract surgery. Leaflets were scored according to the information they provided on: diagnosis, prognosis, treatment options, costs to the patient, details about the procedure, its purpose, likely benefits, how to prepare for it, what to expect during and after the operation, and the common as well as serious complications that may occur. The readability of the information was also assessed.Results: All the units’ leaflets provided information on diagnosis, the lifestyle changes required postoperatively, and cost involved to the patient. Only five units had leaflets that mentioned the risks involved in cataract surgery. The other areas of information were covered by 50–75% of the leaflets. Fifty per cent of the leaflets included a diagram. The average SMOG readability score was high.Conclusion: Although present cataract information leaflets make some contribution to the process of informed consent, most do not address important areas outlined by the General Medical Council. Many of the areas of information that are required for informed consent could easily be covered, and should be borne in mind when designing patient information leaflets. Resources are available on the internet including toolkits, guides, and means of assessment for the production of patient information leaflets. (shrink)

It is broadly held that confidentiality may be breached when doing so can avert grave harm to a third party. This essay challenges the conventional wisdom. Neither legal duties, personal morality nor personal values are sufficient to ground professional obligations. A methodology is developed drawing on core professional values, the nature of professions, and the justification for distinct professional obligations. Though doctors have a professional obligation to prevent public peril, they do not honor it by breaching confidentiality. It is shown (...) how the protective purpose to be furthered by reporting is defeated by the practice of reporting. Hence there is no conflict between confidentiality and the professional responsibility to protect endangered third parties. (shrink)

Bioethics, Volume 36, Issue 1, Page 54-62, January 2022.

The objective of this study was to take a closer look at defense-related expenses for medical malpractice cases over time. We conducted a retrospective review of medical malpractice claims reported to the Physician Insurers Association of America's Data Sharing Project with a closing date between January 1, 1985 and December 31, 2008. On average a medical malpractice claim costs more than $27,000 to defend. Claims that go to trial are much more costly to defend than are those (...) that are dropped, withdrawn, or dismissed. However, since the overwhelming majority of claims are dropped, withdrawn, or dismissed, the total amount spent to defend them surpasses that spent on claims that go to trial. Defense attorney expenses account for the majority of defense-related expenses (74%), while expert witness expenses and other expenses split the remaining 26%. A strong association was also found between the average indemnity payment and the amount it costs to defend individual claims by specialty. Our study found that defense-related expenses for medical malpractice claims are not an insignificant cost. As state and federal governments debate how to repair the malpractice system, addressing the high cost of defending claims should not be ignored. (shrink)

Whenever health care reform is debated, the state of the medical professional liability system in the United States re-emerges as an issue of importance. What exactly is broken with the MPL system and what the implications are is a point of contention among different stakeholder groups. Recent data demonstrate that medical liability premiums have been improving in recent years and the majority of premiums remained flat in 2010. General agreement still exists, however, that medical professional liability insurance (...) premiums have become unaffordable for many physicians, and coverage has become less available, especially for certain medical specialties and in specific areas of the country.Multiple factors go into the determination of medical professional liability insurance premiums including return on investments, reinsurance costs, claims frequency, average amount paid out on malpractice claims, defense expenses, and administrative costs such as underwriting expense. (shrink)

Questions about the dignity of the human person give rise to many of the most central and hotly disputed topics in bioethics. In _A Defense of Dignity: Creating Life, Destroying Life, and Protecting the Rights of Conscience_, Christopher Kaczor investigates whether each human being has intrinsic dignity and whether the very concept of "dignity" has a useful place in contemporary ethical debates. Kaczor explores a broad range of issues addressed in contemporary bioethics, including whether there is a duty of "procreative (...) beneficence," the ethics of ectopic pregnancy, and the possibility of "rescuing" human embryos with human wombs or artificial wombs. _A Defense of Dignity_ also treats issues relevant to the end of life, including physician-assisted suicide, provision of food and water to patients in a persistent vegetative state, and how to proceed with organ donation following death. Finally, what are the duties and prerogatives of health care professionals who refuse in conscience to take part in activities that they regard as degrading to human dignity? Should they be forced to do what they consider to be violations of the patient's well being, or does patient autonomy always trump the conscience of a health care professional? Grounded in the Catholic intellectual and moral tradition, _A Defense of Dignity_ argues that all human beings from the beginning to the end of their lives should be treated with respect and considers how this belief should be applied in controversial cases. "_A Defense of Dignity_ provides a skillful, informed, and clear philosophical analysis, from a natural law perspective, of a range of controversial, and sometimes complex, bioethical questions concerning the beginning and end of life. Few authors approach bioethics from a natural law perspective, and few do it as well as Christopher Kaczor. The book should be of interest not only to natural law philosophers and their students, but also to anyone interested in bioethics." —_John Keown, Georgetown University__ "Moral questions at the beginning and ending of life and controversies over liberty of conscience are among the most vexing and important issues of our day. Christopher Kaczor brings his characteristic moral seriousness and philosophical good sense to his treatment of these issues, all of which implicate the key concept of human dignity. This eminently readable collection will provide an invaluable resource for educators and students alike." — Christopher Tollefsen, University of South Carolina_ “Indispensable. Kaczor untangles the various meanings of human dignity to undertake a reexamination of the most serious and difficult issues in medical ethics. The book combines clarity with philosophical precision, faithfulness to Catholic teaching with a thorough engagement with critics." —_J. Budziszewski, University of Texas at Austin_. (shrink)

Medical indemnity is not usually the stuff of high political and social drama in Australia. When the biggest medical defense organization went into voluntary liquidation in 2002, this all changed. Newspapers carried stories on an almost daily basis about the actual or possible negative impact of the “crisis” on doctors, hospitals, and communities. Doctors became increasingly vocal in their criticisms and expansive in their claims. Their political organization, the Australian Medical Association, lobbied powerfully and successfully for government (...) intervention to address the problem of dramatically escalating premiums for some doctors. This, combined with a broader public relations campaign about public liability insurance, resulted in significant changes in the law at both the federal and state level - not just in the area of medical negligence but in relation to most personal injury litigation.The genesis of and reasons for current medical indemnity problems in Australia have been the subject of much speculation and little rigorous analysis. (shrink)

Medical indemnity is not usually the stuff of high political and social drama in Australia. When the biggest medical defense organization went into voluntary liquidation in 2002, this all changed. Newspapers carried stories on an almost daily basis about the actual or possible negative impact of the “crisis” on doctors, hospitals, and communities. Doctors became increasingly vocal in their criticisms and expansive in their claims. Their political organization, the Australian Medical Association, lobbied powerfully and successfully for government (...) intervention to address the problem of dramatically escalating premiums for some doctors. This, combined with a broader public relations campaign about public liability insurance, resulted in significant changes in the law at both the federal and state level - not just in the area of medical negligence but in relation to most personal injury litigation.The genesis of and reasons for current medical indemnity problems in Australia have been the subject of much speculation and little rigorous analysis. (shrink)

A novel method of teaching military medical ethics, medical ethics and military ethics in the Israel Defense Force (IDF) Medical Corps, essential topics for all military medical personnel, is discussed. Very little time is devoted to medical ethics in medical curricula, and even less to military medical ethics. Ninety-five per cent of American students in eight medical schools had less than 1 h of military medical ethics teaching and few knew the (...) basic tenets of the Geneva Convention. Medical ethics differs from military medical ethics: the former deals with the relationship between medical professional and patient, while in the latter military physicians have to balance between military necessity and their traditional priorities to their patients. The underlying principles, however, are the same in both: the right to life, autonomy, dignity and utility. The IDF maintains high moral and ethical standards. This stems from the preciousness of human life in Jewish history, tradition and religious law. Emphasis is placed on these qualities within the Israeli education system; the IDF teaches and enforces moral and ethical standards in all of its training programmes and units. One such programme is ‘Witnesses in Uniform’ in which the IDF takes groups of officers to visit Holocaust memorial sites and Nazi death camps. During these visits daily discussions touch on intricate medical and military ethical issues, and contemporary ethical dilemmas relevant to IDF officers during active missions. (shrink)

A large slice of contemporary phenomenology of medicine has been devoted to developing an account of health and illness that proceeds from the first-person perspective when attempting to understand the ill person in contrast and connection to the third-person perspective on his/her diseased body. A proof that this phenomenological account of health and illness, represented by philosophers, such as Drew Leder, Kay Toombs, Havi Carel, Hans-Georg Gadamer, Kevin Aho, and Fredrik Svenaeus, is becoming increasingly influential in philosophy of medicine and (...) medical ethics is the criticism of it that has been voiced in some recent studies. In this article, two such critical contributions, proceeding from radically different premises and backgrounds, are discussed: Jonathan Sholl’s naturalistic critique and Talia Welsh’s Nietzschean critique. The aim is to defend the phenomenological account and clear up misunderstandings about what it amounts to and what we should be able to expect from it. (shrink)

We propose that doping be legalized under medical supervision. First, we discuss two motivations for allowing medically supervised doping. We reject the ‘compromised choice/harm minimization’ motivation as unlikely to win the support of athletes. We agree that it could lead to an arms race. Instead, we favor full acceptance of doping under medical supervision and answer Reid’s spirit of sport objection to medical manipulation. After presenting a set of guiding principles, we use them to answer the arms (...) race objection and rebut one of the most prominent objections in the literature about the safety of medically supervised doping, the game-theoretic objection. (shrink)

For a number of reasons, casuistry has come into vogue in medical ethics. Despite the frequency with which it is avowed, the application of casuistry to issues in medical ethics has been given virtually no systematic defense in the ethics literature. That may be for good reason, since a close examination reveals that casuistry delivers much less than its advocates suppose, and that it shares some of the same weaknesses as the principle-based methods it would hope to supplant.

The concept of whole‐brain death is under attack again. Scholars are arguing that the concept of brain death per se—regardless of the focus on “higher,” “stem” or “whole”—is fundamentally flawed. These scholars have identified what they believe are serious discrepancies between the definition and criterion of brain death, and have pointed out that medical professionals and lay persons remain confused about its meaning. Yet whole‐brain death remains the standard for determining death in much of the Western world and its (...) defenders believe this concept best maps onto our everyday conception of death. (shrink)

Robert Baker and Rosamond Rhodes each argue against the universality “common morality,” the approach to ethics that comprises four fundamental principles and their application in various settings. Baker contends that common morality cannot account for cultural diversity in the world and claims that a human rights approach is superior in the context of global health. Rhodes maintains that bioethics is not reducible to common morality because medical professionals have special privileges and responsibilities that people lack in everyday life. Baker (...) fails to demonstrate how the human rights approach to global ethics is more sensitive to culture than the use of bioethics principles that comprise common morality. Rhodes has a narrow interpretation of “common morality,” which when understood more broadly, accounts for the special privileges and obligation of medical professionals. (shrink)

Le présent article s’intéresse aux arguments égalitariens qui défendent une ouverture des frontières nationales car ces dernières discriminent injustement, selon eux, les perspectives individuelles à l’échelle mondiale. Pour égaliser des opportunités aujourd’hui séparées par les frontières des États, il faudrait généraliser la liberté de mouvement transnationale. Nous confrontons cette thèse au cas de l’Union européenne où le statut des Européens circulant librement dans un autre pays leur a progressivement donné les mêmes droits sociaux que ceux dont jouissent les ressortissants (...) du pays d’accueil. Cela a contribué à égaliser les opportunités à l’échelon européen malgré l’absence d’harmonisation des systèmes de protection sociale et de leur financement. À partir de quelques arrêts de la Cour de justice de l’Union européenne, nous confrontons la thèse égalitarienne à trois réserves. La première, qui souligne la menace de la liberté de circulation pour la justice sociale intérieure, est rejetée pour des raisons empiriques. La seconde concerne la possibilité pour la liberté de circulation d’être le support de droits sociaux. Enfin, l’absence de solidarité dans l’Union européenne révèle que la défense égalitarienne d’une ouverture des frontières peut difficilement valoir sans être assortie de mécanismes distributifs au niveau européen. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:_Russell_ journal (home office): E:CPBRRUSSJOURTYPE2602\REVIEWS.262 : 2007-01-24 01:12 Reviews 187 NUCLEAR WAR AND WORLD CITIZENSHIP Chad Trainer 1006 Davids Run Phoenixville, pa 19460, usa [email protected] Robert Hinde and Joseph Rotblat. War No More: Eliminating Conflict in the Nuclear Age. London and Sterling, Va.: Pluto P., 2003. Pp. x, 228. £40.00; us$50.00; isbn 0745321925 (hb). £11.99; us$17.95 (pb). ast year marked the 50th anniversary of the Russell–Einstein Manifesto, Lwhich sought (...) to put the world on guard against the hydrogen bomb’s dangers. The last surviving signatory to the manifesto was Joseph Rotblat, who died on 31 August 2005. In 1995, Rotblat and the Pugwash Conferences were awarded the Nobel Prize for Peace. During World War ii, Joseph Rotblat participated in the Manhattan Project to develop an atomic bomb. An Encyclopaedia Britannica article on his Nobel prize explains that “Although he was uncomfortable about participating in the creation of an atomic bomb, Rotblat initially believed that the weapon would be used only to deter a German threat. After learning in 1944 that it would be used to contain the Soviet Union, a World War ii ally, he left the project….” Upon returning to England in 1945, Rotblat left defence work for medical research. He served as founding secretary-general and later as president of the Pugwash Conferences on Science and World Affairs, which began in 1957 and at which key scientists and others from different countries could confer about the peril of nuclear weapons facing the world. As a medical physicist at London University’s St. Bartholomew’s Hospital Medical College (1950–76), Rotblat directed attention toward the biological hazards of nuclear radiation and the severity of fallout from atmospheric testing. He worked closely with Russell in the 1950s and early ’60s and still visited him in his last years. (See his “Personal Reminiscences”, Russell, 18 [1998]: 5–24.) The book’s co-author, Robert Hinde, is the author of numerous books and articles in psychology. The book addresses the planet’s current state in terms of weapons of mass destruction. It features many tables and charts on matters ranging from the varying levels of the super-powers’ nuclear warhead stockpiles to the principal nuclear arms control treaties to estimates of military deaths in individual wars during the last 60 years. Since this book is an earnest endeavour to address the issue of weapons of mass destruction, many of its most fundamental prescriptions sound basic, even _Russell_ journal (home office): E:CPBRRUSSJOURTYPE2602\REVIEWS.262 : 2007-01-24 01:12 188 Reviews somewhat banal. To be sure, the authors acknowledge that “Any attempt to discuss ways of preventing war must address very basic issues, and in so doing lays itself open to accusations of mushy idealism” (pp. 214–15). In War No More the authors opt to err in the direction of moral truisms as a small price to pay if there is a chance of contributing to a discussion eventually compelling the world’s political leaders to heed such moral considerations. In the prevention of conflict, “Often the success of such efforts may be unknown to the wider world just because the criterion of success is simply that nothing happens” (p. 198). Hinde and Rotblat urge their readers to understand the absolute need to abolish war if humanity is to endure in this nuclear age. Their position is that “the very possession of nuclear weapons is immoral. Their enormous destructive power, inflicted on civilians even more than on the military, would make their use unforgiveable” (p. 139). The authors expressly credit Bertrand Russell and Albert Einstein with having taken the initiative for international action on this front (p. 189). And as was the view of Russell and Einstein 50 years earlier, Hinde and Rotblat proclaim in their book that “The only solution is international agreement on the total abolition of nuclear weapons” (p. 139). Hinde and Rotblat concede the ease with which people can be pessimistic about the prospects of abolishing war. However, the formidable challenge posed by such a task is deemed “no excuse for inaction”. They cite historic instances in which humanity has... (shrink)

Nutrition and hydration are common problems in advanced dementia. There has been growing opposition to the use of tube feeding in these patients both in and out of the Catholic Church. This article takes a critical look at current medical research on the subject and presents a vigorous defense of the use of artificial nutrition and hydration in dementia. A revealing case study is presented and a clear medical and ethical rationale are offered to support the appropriate use (...) of ANH in accord with Church teaching. National Catholic Bioethics Quarterly 9.4 (Winter 2009): 697–710. (shrink)

Arguments that medical decision making should rely on a variety of evidence often begin from the claim that meta-analysis has been shown to be problematic. In this paper, I first examine Stegenga’s argument that meta-analysis requires multiple decisions and thus fails to provide an objective ground for medical decision making. Next, I examine three arguments from social epistemologists that contend that meta-analyses are systematically biased in ways not appreciated by standard epistemology. In most cases I show that critiques (...) of meta-analysis fail to account for the full range of meta-analytic procedures. In the remainder of cases, I argue that the critiques identify problems that do not uniquely cut against meta-analysis. I close by suggesting one reason why it may be pragmatically rational to violate the principle of total evidence and by outlining the criteria for a successful argument against meta-analysis. A set of criteria I contend remain unmet. (shrink)

With the escalation of terrorism worldwide in recent years, situations arise in which the perpetration of violence and the defense of human rights come into conflict, creating serious ethical problems. The Geneva Convention provides guidelines for the medical treatment of enemy wounded and sick, as well as prisoners of war. However, there are no comparable provisions for the treatment of terrorists, who can be termed unlawful combatants or unprivileged belligerents. Two cases of severely injured terrorists are presented here to (...) illustrate the dilemmas facing the medical staff that treated them. It is suggested that international legal and bioethical guidelines are required to define the role of the physician and auxiliary medical staff vis a vis injured terrorists. There are extreme situations where the perpetration of violence and the defense of human rights come into conflict, leading to serious ethical and psychological discord. Terrorists, using violence to create fear in order to further their political objectives, might require life-saving medical care if injured during the course of their terror activities. (shrink)

"An American psychologist, Daniel N. Robinson, traces the development of the insanity plea...[He offers] an assured historical survey." Roy Porter, The Times [UK] "Wild Beasts and Idle Humours is truly unique. It synthesizes material that I do not believe has ever been considered in this context, and links up the historical past with contemporaneous values and politics. Robinson effortlessly weaves religious history, literary history, medical history, and political history, and demonstrates how the insanity defense cannot be fully understood without (...) consideration of all these sources." Michael L. Perlin, New York Law School "Daniel N. Robinson has written a graceful history of insanity and the law stretching from Homer to Hinckley. He attempts no final theory as to how the law should cope with the insane; he seeks, rather, to use the shifting notions of when madness exculpates criminal activity to illuminate the core self-perceptions of the cultures developing ever-evolving resolutions of the problem...[T]he grandeur of the theme...commands attention and respect." --Neal Johnston, The Nation . (shrink)

Intuition in medical and moral reasoning -- Moral intuitionism -- The place of Aristotelian phronesis in clinical reasoning -- Aristotle's practical syllogism: accounting for the individual through a theory of action and cognition -- Individual and statistical physiognomy: the art and science of making the invisible visible -- Clinical intuition versus statistical reasoning -- Contingency and correlation: the significance of modeling clinical reasoning on statistics -- Abduction: the intuitive support of clinical induction -- Conclusion: medical ethics beyond ontology.

The philosopher Henry Richardson's short book is a defense of a position on a neglected topic in medical research ethics. Clinical research ethics has been a longstanding area of study, dating back to the aftermath of the Nazi death-camp doctors and the Tuskegee syphilis study. Most ethical regulations and institutions have developed in response to those past abuses, including the stress on obtaining informed consent from the subject. Richardson points out that that these ethical regulations do not address one (...) of the key dilemmas faced by medical researchers -- whether or not they have obligations towards subjects who need care not directly related to the purpose of the study, termed 'ancillary care obligation'. (shrink)

A number of recent publications by the philosopher David Seedhouse are discussed. Although medicine is an eminently ethical enterprise, the technical and ethical aspects of health care practices can be distinguished, therefore justifying the existence of medical ethics and its teaching as a specific part of every medical curriculum. The goal of teaching medical ethics is to make health care practitioners aware of the essential ethical aspects of their work. Furthermore, the contention that rational bioethics is a (...) fruitless enterprise because it analyses non-rational social events seems neither theoretically tenable nor to be borne out by actual practice. Medical ethics in particular and bioethics in general, constitute a field of expertise that must make itself understandable and convincing to relevant audiences in health care. (shrink)

Misuse or misunderstanding of medication information is a common and costly problem in the U.S. The risks of misunderstanding medication information are compounded for the large and growing population of individuals with limited English proficiency that often lacks access to this information in their own language. This paper examines practices related to translation of medication information in the European Union that may serve as a model for future U.S. policy efforts to improve the quality and availability of medication information (...) for individuals with limited English proficiency. (shrink)

This brief essay critiques the torture memoranda's use of the necessity defense from the perspectives of criminal law doctrine, criminal law theory, and moral philosophy.

Most agree that clinical research offers one of the best prospects of improving pediatric medicine. Most also agree that children may be exposed to some degree of risk while participating in clinical trials. But the degree of risk that should be permitted and the reasons for which it should be permitted remain controversial. In this paper, I examine a central risk threshold in research with children—the threshold constraining risks that do not offer research subjects the prospect of direct medical (...) benefit. That is, the threshold for research risks undertaken in the interests of deriving valuable knowledge that may benefit future children, but not the research subjects themselves. I examine competing... (shrink)

Monetary compensation for human eggs used in research is a controversial issue and raises major concerns about women’s health and rights, including the potential of exploitation and undue inducement. Human eggs are needed for various types of studies and without payment, it would be impossible to procure sufficient eggs for vital research. Therefore, a solution seems necessary to prevent exploitation and resolve other ethical concerns while ensuring sufficient supplies of human eggs for research. A brief review of legislation in different (...) countries shows the existing diversity and controversy over compensating human egg donation for research purposes. While in more economically developed countries procreative liberty and consumer orientation seem to be defensible, in some developing countries, where concerns about exploitation exist, adopting a more regulated approach to assisted reproduction is more prudent and wise. Egg sharing is a program that has been proposed to solve both the ethical problems of purchasing eggs and the shortage of human egg supply for research. In developing countries, however, regardless of whether the egg sharing or the monetary compensation model is adopted, some steps should be taken to guarantee the ethical nature of this practice. These steps include ensuring the existence of independent institutional review boards, confirming the validity of all steps in the process of obtaining informed consent, and ensuring the existence and viability of independent supervising and auditing bodies. (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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I am grateful to the esteemed commentators for their critiques of my paper, ‘Why Not Common Morality’.1 As I read through their remarks, however, they seemed to be talking past my arguments. Their criticisms nevertheless make it clear that I need to explain myself better. I am therefore grateful to the editor for allowing me this opportunity to clarify my position. My paper presented two arguments for concluding that common morality is untenable as an account of medical ethics. First, (...) I provided a negative argument to show that common morality does not provide an adequate account of medical ethics. Second, I offered a positive argument that demonstrated why the medical professions require a distinct morality. My negative argument relies on counterexamples to show that the duties of medicine are different from the duties of everyday life. It is intended as a refutation of the claim by Tom Beauchamp and James Childress that ‘The common morality is applicable to all persons in all places, and we rightly judge all human conduct by its standards’.2 Logically, if any of the duties of medical ethics are inconsistent with common morality, they are not compatible with common morality standards. My counterexamples demonstrate that standards of conduct judged acceptable by common morality are irreconcilable with duties of medical ethics. Hence, they could not follow from the same principles. If the standards of common morality lead to particular judgments about the morality of a certain conduct, those same standards cannot also be the basis for reaching the opposite judgments about that sort of conduct. Charles Foster,3 Alex John London,4 Ruth Macklin5 and Bryanna Moore6 all suggest that exceptions to my examples refute my negative argument. As far as they go, …. (shrink)

In 1959 two French neurologists, Pierre Mollaret and Maurice Goullon, coined the term coma dépassé to designate a state beyond coma. In this state, patients are not only permanently unconscious; they lack the endogenous drive to breathe, as well as brainstem reflexes, indicating that most of their brain has ceased to function. Although legally recognized in many countries as a criterion for death, brain death has not been universally accepted by bioethicists, by the medical community, or by the public. (...) I this paper, I defend brain death as a biological concept. I challenge two assumptions in the brain death literature that have shaped the debate and have stood in the way of an argument for brain death as biological. First, I challenge the dualism established in the debate between the body and the brain. Second, I contest the emphasis on consciousness, which prevents the inclusion of psychological phenomena into a biological criterion of death. I propose that the term organism should apply both to the functioning of the body and the brain. I argue that the cessation of the organism as a whole should take into account three elements of integrated function. Those three elements are: 1) the loss of integrated bodily function; 2) the loss of psychophysical integration required for processing of external stimuli and those required for behavior; and, 3) the loss of integrated psychological function, such as memory, learning, attention, and so forth. The loss of those three elements of integrated function is death. (shrink)

Abstract:There is a role for regulatory oversight over new genetic technologies. Research must ensure the rights of human subjects, and all medical products and techniques should be ensured to be safe and effective. In the United States, these forms of regulation are largely the purview of the National Institutes of Health and the Food and Drug Administration. Some have argued, however, that human genetic therapies require new regulatory agencies empowered to enforce cultural norms, protect against hypothetical social harms, or (...) ensure that the human genome remains unchanged. Focusing on the United States, this essay will briefly review these arguments and argue that the current limited regulatory role over human gene therapies is sufficient to protect public health, bodily autonomy, and reproductive freedom. (shrink)

The prelims comprise: Background: The Concept of Information Management Clearing the Ground: What Professional Obligations are Not The Concept of a Professional Obligation The Duty to Diminish Risks to Third Parties A Defense of Unqualified Confidentiality Final Thoughts Notes.

Economists of the Austrian School are supporters of the gold standard because it hinders and restricts arbitrary policies and rulers: it disciplines the behavior of all the agents involved in the democratic process and encourages people to act orderly and morally. It is, in fact, an obstacle to the lies and demagoguery because it spreads and facilitates transparency and truth in social relations. The creation of the euro in 1999 and its final implementation in 2002 assumed the disappearance of monetary (...) nationalism and flexible exchange rates in most of continental Europe. We will discuss the errors committed by the European Central Bank. It is now seen how the different states of the European Monetary Union have given and completely lost their monetary autonomy, that is to say the ability to manipulate their local currency to serve political needs. In this sense, the euro has therefore acted, at least for the countries of the euro area, very similar to that which was, in its time, the gold standard manner. This is why the euro should be considered a real equivalent, albeit imperfect, of the gold standard. (shrink)

One of the most challenging issues in medical ethics is a permission or prohibition of euthanasia. Is a patient with an incurable disease who has lots of pain permitted to kill oneself or ask others to do that? The main reason advanced by the opponents is the absolute prohibition of murder. Accordingly, the meaning of murder plays a key role in determining the moral judgment of euthanasia. The aim of this paper is to confirm the role of intention in (...) moral judgment of euthanasia and eliminate the name of unjust murder from voluntary euthanasia. The Intention of an agent determines the name of the act and whether it is right or wrong. An important point that dose not taken into account in the definitions of murder, killing as well as their ethical judgment is considering the attributes of being unjust and forcible. Killing a human being is neither intrinsically good nor bad, but its ethical judgment depends on the way that happens, i.e. just or unjust. Every killing is neither bad nor unethical except unjust one which is both bad and unethical. The attribute of “unjust” has been mentioned in the definition of murder in Islamic jurisprudence, law, traditions, and Quran. Owing to this argument, on one hand, it is true to state that voluntary euthanasia is not unjust and forcible murder (the test of correct negation), and on the other hand, it is not true to say that voluntary euthanasia is unjust and forcible murder (the test of incorrect predication). It can be concluded that voluntary euthanasia is an independent title other than unjust murder and does not have its judgment. (shrink)

International Humanitarian Law mandates that all wounded in war, no matter which party they belong to, shall receive aid in accordance with their medical condition, and that “there shall be no distinction among them founded on any grounds other than medical ones.” This principle of impartiality is endorsed by various other military and civilian institutions worldwide to include the ICRC, the US Department of Defense, and the American Medical Association. In this essay, I argue that in some (...) cases, we ought, morally speaking, to triage based on factors beyond one’s medical condition. More specifically, I argue that in these cases, we ought to triage, at least partly, based on one’s moral responsibility for one’s current medical predicament. I call this view Triage by Moral Responsibility (TMR). I support my argument for TMR by demonstrating its plausibility when applied to cases of medical treatment and disaster relief, and by drawing parallels between these situations and those considered in the ethics of defensive harming. I conclude by discussing the practicality of my moral conclusion for the practice of medical triage in pandemics and war. (shrink)

This essay discusses unlimited insurance subrogation (UIS) as a means of improving the deterrence and compensation results of medical malpractice law. Under UIS, health care insureds could assign their entire potential medical malpractice claims to their first-party commercial and government insurers. UIS should improve deterrence by establishing first-party insurers as plaintiffs to confront liability insurers on the defense side, leading to more effective prosecution of meritorious claims and reducing meritless and unnecessary litigation. UIS should improve compensation outcomes by (...) converting litigation cost- and risk- laden “tort insurance” into cheaper and enhanced first-party insurance. UIS also promises dynamic benefits through further reforms by contract between the first-party and liability insurers that would take charge of system. No UIS-related costs are apparent that would outweigh these benefits. (shrink)

With the escalation of terrorism worldwide in recent years, situations arise in which the perpetration of violence and the defense of human rights come into conflict, creating serious ethical problems. The Geneva Convention provides guidelines for the medical treatment of enemy wounded and sick, as well as prisoners of war. However, there are no comparable provisions for the treatment of terrorists, who can be termed unlawful combatants or unprivileged belligerents. Two cases of severely injured terrorists are presented here to (...) illustrate the dilemmas facing the medical staff that treated them. It is suggested that international legal and bioethical guidelines are required to define the role of the physician and auxiliary medical staff vis a vis injured terrorists. There are extreme situations where the perpetration of violence and the defense of human rights come into conflict, leading to serious ethical and psychological discord. Terrorists, using violence to create fear in order to further their political objectives, might require life-saving medical care if injured during the course of their terror activities. (shrink)

Since the advent of drug regulation in 1962, regulatory agencies have been in the practice of using strict standards to test the safety and efficacy of medical treatments and products. Regulatory agencies, such as the FDA, demand two full-fledged Randomized Clinical Trials demonstrating the safety and effectiveness of drugs to grant its marketing authorization. On the contrary, surgical treatments are left completely unregulated. There are several reasons explaining this difference, and all of them point to the difficulty of conducting (...) well-designed RCTs in surgery. However, we argue that none of these arguments is decisive and that, under certain conditions, surgical RCTs can be morally justified and methodologically sound. Although ethical constraints restrict the number of testable surgical procedures, and surgical trials might not be as dependable as pharmaceutical RCTs, our analysis suggests that, in certain cases, it is possible to obtain high-quality evidence about the safety and efficacy of surgical procedures. Untested surgical treatments may prove to be ineffective and harm patients. Therefore, regulation of surgical procedures seems not only morally acceptable and able to provide reliable scientific evidence, but also desirable and justified from an ethical-political standpoint. (shrink)

An American medical ethicist finds the spirit of glasnost and perestroika permeating Soviet medical ethics. These themes, along with a heightened historical consciousness, and a commitment to the Hippocratic tradition, have reinforced a conviction about the infinite value of life.

The goal of military medicine is to conserve the fighting force necessary to prosecute just wars. Just wars are defensive or humanitarian. A defensive war protects one's people or nation. A humanitarian war rescues a foreign, persecuted people or nation from grave human rights abuse. To provide medical care during armed conflict, military medical ethics supplements civilian medical ethics with two principles: military-medical necessity and broad beneficence. Military-medical necessity designates the medical means required to (...) pursue national self-defense or humanitarian intervention. While clinical-medical necessity directs care to satisfy urgent medical needs, military-medical necessity utilizes medical care to satisfy the just aims of war. Military medicine may therefore attend the lightly wounded before the critically wounded or use medical care to win hearts and minds. The underlying principle is broad, not narrow, beneficence. The latter addresses private interests, while broad beneficence responds to the collective welfare of the political community. (shrink)

Clinical ethics consultants respond to a multitude of issues, ranging from the cognitive to the emotional. As such, ethics consultants must be prepared to analyze as well as empathize. And yet, there remains a paucity of research and training on the interpersonal and emotional aspects of clinical ethics consultations—the so-called skills in “advanced ethics facilitation.” This article is a contribution to the need for further understanding and practical knowledge in the emotional aspects of ethics consultation. In particular, I draw attention (...) to defense mechanisms: what they are, why they exist, and how we might work with them in the setting of ethics consultation. (shrink)

All illness represents a state of diminished autonomy and therefore the doctor-patient relationship necessarily and justifiably involves a degree of medical paternalism argues the author, an American medical student. In a broad-ranging paper he discusses the concepts of autonomy and paternalism in the context of the doctor-patient relationship. Given the necessary diminution of autonomy which illness inflicts, a limited form of medical paternalism, aimed at restoring or maximising the patient's autonomy is entirely acceptable, and indeed fundamental to (...) the relationship he argues. However, the exercise of this paternalism should be flexible and related to the current 'level of autonomy' of the patient himself. An editorial in this issue comments briefly on this paper. (shrink)

In this essay, I defend rights of conscientious objection against various objections raised on deontological grounds of rights and entitlements as well as on consequentialist, utilitarian grounds. Udo Schuklenk and Ricardo Smalling in their article, “Why Medical Professionals Have No Moral Claim to Conscientious Objection Accommodation in Liberal Democracies” raise various objections, including the Objection from the Rights of Patients, the Objection from Monopoly, the Objection from Religion, the Objection from Untestability, and the Objection from Inconsistency. This article also (...) responds to the concern about “unconstrained conscientious objection.” It suggests that we can distinguish legitimate from illegitimate conscientious objection in part by means of distinguishing objection to particular kinds of procedures from objection to treating particular kinds of persons. Perhaps the most promising way of differentiating legitimate from illegitimate conscientious objection in healthcare is by means of the goal of the medical art understood as the promotion of health. (shrink)