These essays examine the ways in which the consideration of ethical questions is shaped by the structures of knowledge and communication at work in clinical ...

Vaccination is a highly effective public health strategy that provides protection to both individuals and communities from a range of infectious diseases. Governments monitor vaccination rates carefully, as widespread use of a vaccine within a population is required to extend protection to the general population through “herd immunity,” which is important for protecting infants who are not yet fully vaccinated and others who are unable to undergo vaccination for medical or other reasons. Australia is unique in employing financial incentives to (...) increase vaccination uptake, mainly in the form of various childcare payments and tax benefits linked to timely, age-appropriate vaccination. Despite relatively high compliance with the childhood vaccination schedule, however, the Australian government has determined that rates should be higher and has recently introduced policy that includes removing certain tax and childcare benefits for non-vaccinators and formally disallowing conscientious objection to vaccination. In addition, it has raised the possibility of banning unvaccinated children from childcare centres. This article examines the impact of coercive approaches to childhood vaccination and raises the question of the ethical justification of health policy initiatives based on coercion. We consider the current evidence regarding childhood vaccination in Australia, the small but real risks associated with vaccination, the ethical requirement for consent for medical procedures, and the potential social harms of targeting non-vaccinators. We conclude that the evidence does not support a move to an increasingly mandatory approach that could only be delivered through paternalistic, coercive clinical practices. (shrink)

Recognizing the potential hidden artistic contributions of persons with dementia opens new opportunities for interpretation and potential communication. This visual essay explores the authors’ responses to the fragile objects of art produced by a person with severe dementia and examines what may be learned from them.

This article reflects on the assumption underlying the argument of Little et al. that "contested understandings" in the clinic are susceptible to reconciliation within a liberal framework described as "pragmatic pluralism". It is argued that no such reconciliation is possible or desirable because it is of the nature of the clinic that it provides a forum for multiple voices, ethical and cultural perspectives, and conceptual frameworks, and this is the source of its fecundity and creativity. Medicine itself cannot be represented (...) by a single discourse, precisely because it is itself an unruly collection of practices that, despite their heterogeneity, are able to engage in productive dialogues with each other. The heteroglossia of the clinic, therefore, is not a problem to be overcome. Rather, it is a rich resource to be mobilized in accordance with its multiple inherent purposes. (shrink)

The Arab and Islamic world is in cultural, political and ethical flux. Pressures of globalisation contend with ancient ideas and concepts that permeate cultural frameworks. Health professionals are among the many groups battling to accommodate the rapidly changing conditions. In many predominantly Muslim countries intense debates are underway among clinicians about the impact of the forces of change on their practices. To help understand these forces we conducted a study of the experiences of clinicians in the Hashemite Kingdom of Jordan, (...) a Middle Eastern nation state where the overwhelming majority of the population is Muslim. The sample contained 508 doctors and doctors-in-training, of whom 63% were male and 80% were younger than 40 years of age. It included both a quantitative survey, covering a wide range of issues, and qualitative, free-text written responses. Our results demonstrated high levels of disquiet related to the overall organisation and administration of the health care system, the specific content of ethical decisionmaking, and the impact of changing social, cultural and religious factors. Concerns included overcrowding, widespread corruption and hierarchical, non- democratic, management practices, and tensions relating to traditional and modern approaches to ethics, especially in relation to consent, organ donation, confidentiality, privacy, abortion, and the role of women. The roles of religion and religious authorities, the relative importance of the family, and community and tribal obligations were also areas of contention. The study exposes profound divisions and widely differing perspectives among Jordanian doctors and an abiding sense of uncertainty and instability within the profession. Many doctors express ambivalence in relation to both modern trends and traditional precepts. Three main axes of ethical contention were demonstrated, relating to the tensions between: "conservative" and "pragmatic" styles of decision-making; "traditional" approaches and internationalised standards of ethics; and the role of Islam and pressures to disengage ethical decision- making from religious authority. We speculate that these issues and divisions, and the deep sense of disquiet revealed by our data reflect large-scale forces to which Jordanian society is exposed and to a substantial degree may provide a way to understand the ethical predicament of many other countries in the contemporary Arab world. (shrink)

Dementia is more than a disease. What dementia is, how it is understood, and how it is experienced is influenced by multiple factors including our societal preoccupation with individual identity. This essay introduces empirical and theoretical evidence of alternative ways of understanding dementia that act as a challenge to common assumptions. It proposes that dementia be understood as an experience of systems, particularly networks of people affected by the diagnosis. Taking this step reveals much about the dementia experience, and about (...) what can be learned from persons with dementia and their networks of family, friends, and carers. It also suggests that dementia may be best thought of as an ecology that arises from the interaction between neuropathological change, people, language, and meaning. While challenging, this perspective may provide new ways of responding to dementia and caring for those affected by it. (shrink)

Recent discourses about the legitimacy of homeopathy have focused on its scientific plausibility, mechanism of action, and evidence base. These, frequently, conclude not only that homeopathy is scientifically baseless, but that it is “unethical.” They have also diminished patients’ perspectives, values, and preferences. We contend that these critics confuse epistemic questions with questions of ethics, misconstrue the moral status of homeopaths, and have an impoverished idea of ethics—one that fails to account either for the moral worth of care and of (...) relationships or for the perspectives, values, and preferences of patients. Utilitarian critics, in particular, endeavour to present an objective evaluation—a type of moral calculus—quantifying the utilities and disutilities of homeopathy as a justification for the exclusion of homeopathy from research and health care. But these critiques are built upon a narrow formulation of evidence and care and a diminished episteme that excludes the values and preferences of researchers, homeopaths, and patients engaged in the practice of homeopathy. We suggest that homeopathy is ethical as it fulfils the needs and expectations of many patients; may be practiced safely and prudentially; values care and the virtues of the therapeutic relationship; and provides important benefits for patients. (shrink)

Gerrit Lindeboom’s biography, Herman Boerhaave: The Man and His Work, presents a heroic account of Herman Boerhaave’s life and his many contributions to medicine and medical education. He is portrayed as an outstanding eighteenth century educator who introduced into Leiden’s Medical School a novel method of clinical teaching that was to be widely adopted and today remains at the centre of medical student instruction. Lindeboom’s historiography induced a resurgence of interest in Boerhaave, a renewal of the myth concerning Boerhaave’s innovative (...) teaching and the publication of many acclamatory articles and false epithets, and several critical analyses. Such varying responses prompted this critical examination of the extant Boerhaavian literature, an appraisal of Lindeboom’s objectivity and an assessment of his representations of Boerhaave’s clinical teaching. In doing so, the moral nature of his historiography and that of those who were to sustain his assertions will be established, and the myth that surrounds the novelty and excellence of Boerhaave’s clinical teaching will be evident. (shrink)

Experiments in Love and Death is about the depth and complexity of the ethical issues that arise in illness and medicine. In his concept of 'microethics' Paul Komesaroff provides an alternative to the abstract debates about principles and consequences that have long dominated ethical thought. He shows how ethical decisions are everywhere: in small decisions, in facial expressions, in almost inconspicuous acts of recognition and trust. Through powerful descriptions of case studies and clear and concise explanations of contemporary philosophical theory (...) the book brings discussions about ethics in medicine back to where they belong-to the level of the everyday experience where people actually live, suffer and hope. A fresh and evocative look at the changing world of ethics as it applies to health and illness, this is an important book for all those touched by illness or suffering. About the author Paul Komesaroff is a physician and philosopher at Monash University in Melbourne, Australia. His books include Objectivity, Science and Society, Troubled Bodies, Sexuality and Medicine (ed. with Philipa Rothfield and John Wiltshire) and Pathways to Reconciliation (ed. with Philipa Rothfield and Cleo Fleming). (shrink)

This historiographic survey of extant English translations and interpretations of the renowned Hippocratic first aphorism has demonstrated a concerning acceptance and application of ancient deontological principles that have been used to justify a practice of medicine that has been both paternalistic and heteronomous. Such principles reflect an enduring Hippocratism that has perpetuated an insufficient appreciation of the moral nature of the aphorism’s second sentence in the practice of the art of medicine. That oversight has been constrained by a philological discourse (...) that has centred on the meanings of the aphorism’s first sentence, while little consideration has been given to the more important ethical consideration within the second sentence’s imperatives. (shrink)

Like other Arab countries, Jordan must find ways of responding to the rapid processes of change affecting many aspects of social life. This is particularly urgent in healthcare, where social and technical change is often manifested in tensions about ethical decision-making in the clinic. To explore the attitudes, beliefs and concerns relating to ethical decision-making among health professionals in Jordanian hospitals, a qualitative study was conducted involving face-to-face interviews with medical personnel in four hospitals in Amman, the capital of Jordan. (...) Data were analysed thematically in relation to a pre-existing set of ethical categories. Interviews were conducted with thirty-eight doctors covering most medical specialities. Five major themes emerged from the interviews: ethical awareness, ethical issues, the impact of religion on ethical decision-making, practical and theoretical resources for ethical decision-making, and challenges. While uncertainty was expressed about some aspects of Western approaches to ethics, participants strongly supported adoption of a range of Western bioethical principles, including cultural and ethical diversity, along with adherence to Islamic religious norms. A range of serious ethical challenges facing the Jordanian health system were identified, covering social, legal, managerial, and technical issues. Ethical decision-making in Jordan is complex, having to accommodate the needs of patients, the opinions of doctors and their families, the views of religious authorities, managerial considerations, and both local norms and international standards. Health professionals struggle with three sets of tensions that emerge out of the struggle between traditional, community-embedded forms of social organization and the demands generated by globalization and the influence of Western culture: the tensions between tradition and modernity, conservatism and pragmatism, and religion and secularism. Doctors in Jordan prefer approaches to ethical decision-making that realize a balance between the extremes, although the exact nature of where that balance should lie remains uncertain. (shrink)

Surveillance is a core function of all public health systems. Responses to the COVID-19 pandemic have deployed traditional public health surveillance responses, such as contact tracing and quarantine, and extended these responses with the use of varied technologies, such as the use of smartphone location data, data networks, ankle bracelets, drones, and big data analysis. Applying Foucault’s (1979) notion of the panopticon, with its twin focus on surveillance and self-regulation, as the preeminent form of social control in modern societies, we (...) examine the increasing levels of surveillance enacted during this pandemic and how people have participated in, and extended, this surveillance, self-regulation, and social control through the use of digital media. Consideration is given to how such surveillance may serve public health needs and/or political interests and whether the rapid deployment of these extensive surveillance mechanisms risks normalizing these measures so that they become more acceptable and then entrenched post-COVID-19. (shrink)

This review essay examines the emergence of the patient narrative or “pathography” in the late eighteenth and early nineteenth century in relation to the great cultural, epistemological, and ethical transformations that enabled the formation of modern medicine. John Wiltshire’s book provides an historical overview of this complex process, as well as laying the basis for a contemporary critique of some of its key assumptions.

The focus of discussion about the ethical issues associated with the COVID-19 pandemic has been on the great suffering to which it has given rise. However, there may be some unexpected positive outcomes that also emerge from the global disaster. The rupturing of entrenched systems and processes, the challenging of certainties that seemed beyond question, and the disruption of the assumed consensus of modernity may contribute to a rediscovery of the challenges that compose an ethical life. Elements of such a (...) process are evident in the surge of community support and mutual caring, of spontaneous acts of joyous solidarity, of suspension of past conflicts, and exploration of new forms of reconciliation. The experiences are tentative and the outcomes uncertain, but at least for a moment the hope of a new way forward has been raised. (shrink)

Social, political, and economic environments play an active role in nurturing professional virtue. Yet, these environments can also lead to the erosion of virtue. As such, professional virtue is fragile and vulnerable to environmental shifts. While physicians are often considered to be among the most virtuous of professional groups, concern has also always existed about the impact of commercial arrangements on physicians’ willingness and capacity to enact their professional virtues. This article examines the ways in which commercial arrangements have been (...) negotiated to secure medical virtue from real or perceived threats of erosion. In particular, we focus on the concern surrounding conflicts of interest arising from commercial arrangements that have developed as a result of neoliberal economic and social policies. The deregulation of medical markets and privatization of services have produced new commercial relationships that are often misunderstood by patients, publics, and physicians themselves. ‘Conflicts of interest’ policies have been introduced in an attempt to safeguard ethical conduct and medical practice. However, a number of virtue ethicists have critiqued these policies as inadequate for securing virtue. We examine the ways in which commercial arrangements have been seen to impact upon medical virtue, both historically and in the context of modern medicine. We then describe and critique current efforts to restore clinical virtue through both conflict of interest policies and through virtue ethics. Finally, we suggest some possible ways of addressing the corrosive effects of neoliberalism on medical virtue. (shrink)

Reconciliation and the Technics of Healing Content Type Journal Article Pages 235-237 DOI 10.1007/s11673-011-9318-y Authors Paul A. Komesaroff, Monash Centre for Ethics in Medicine and Society, Monash University, Melbourne, Vic., Australia Elizabeth Kath, Global Cities Institute, RMIT University, Melbourne, Vic., Australia Paul James, Global Cities Institute, RMIT University, Melbourne, Vic., Australia Journal Journal of Bioethical Inquiry Online ISSN 1872-4353 Print ISSN 1176-7529 Journal Volume Volume 8 Journal Issue Volume 8, Number 3.

Learning from the profound challenge of dementia is an urgent priority. Success will require a critical deconstruction of current cultural and linguistic representations of this condition, and a kindling of novel and courageous approaches to re-conceptualise dementia's meaning and experience. This symposium collects provocative ideas arising from various discourses, theoretical perspectives, and methodolgical approaches to explore new ways to understand dementia.

Medical decision making when a patient cannot participate is complicated by the question of whose voice should be heard. The most common answer to this question is that “autonomy” is paramount, and therefore it is the voice of the unwell person that should be given priority. Advance care planning processes and practices seek to capture this sentiment and to allow treatment preferences to be documented and decision makers to be nominated. Despite good intentions, advance care planning is often deficient because (...) it is unable to facilitate a relational approach to decision making in cases when the patient’s competence is reduced. In this article we present findings from a study of the ways in which older people and their significant others understand decision making in such circumstances. Critical to the participants’ understanding was the emergent concept of “relational knowing,” a concept that is poorly articulated in the advance care planning literature. Our findings suggest that the dominant understanding of decision making in conditions of impaired competence is incomplete and obscures much of what matters to people. We conclude that, having recognized a broader set of ethical concerns, it is necessary to develop a relational and narrative based approach that applies in appropriate settings. (shrink)

Originally published in 1986. This work remains of compelling interest to those concerned with the natural sciences and their social problems. It puts forward original and unorthodox ideas about the philosophy of and sociology of science, starting from the conviction that modern societies face deep problems arising from unresolved dilemmas about the meaning, content and technical applications of the theories of nature they employ. The book draws on insights developed within a variety of traditions to explore these problems, especially the (...) work of Edmund Husserl and modern critical theory. (shrink)

Intense public interest in scientific claims about COVID-19, concerning its origins, modes of spread, evolution, and preventive and therapeutic strategies, has focused attention on the values to which scientists are assumed to be committed and the relationship between science and other public discourses. A much discussed claim, which has stimulated several inquiries and generated far-reaching political and economic consequences, has been that SARS-CoV-2 was deliberately engineered at the Wuhan Institute of Virology and then, either inadvertently or otherwise, released to the (...) public by a laboratory worker. This has been pursued despite a clear refutation, through comprehensive genomic analysis, of the hypothesis that the virus was deliberately engineered and the failure of detailed investigations to identify any evidence in support of a laboratory leak. At the same time a substantial, established body of knowledge about the many factors underlying the emergence of novel zoonotic diseases has been largely ignored—including climate change and other mechanisms of environmental destruction, tourism, patterns of trade, and cultural influences. The existence and conduct of these debates have raised questions about the vulnerability of science to manipulation for political purposes. Scientific discourses are vulnerable because: (i) claims can be made with no more than probabilistic force; (ii) alleged “facts” are always subject to interpretation, which depends on social, ethical, and epistemological assumptions; and (iii) science and scientists are not inherently committed to any single set of values and historically have served diverse, and sometimes perverse, social and political interests. In the face of this complexity, the COVID-19 experience highlights the need for processes of ethical scrutiny of the scientific enterprise and its strategic deployment. To ensure reliability of truth claims and protection from corrupting influences robust ethical discourses are required that are independent of, and at times even contrary to, those of science itself. (shrink)

The race against COVID-19 has been intense and painful and many of us are now looking for a way to move on. We may try to seize a degree of comfort and security by convincing ourselves that we are among the “fittest”—that is, among those who have managed to survive—who can now hope for a “new-normal” time, relatively unscathed. But this isn’t what we should be hoping for. Our world, and ourselves, will never be free of COVID-19 or its insidious (...) effects. COVID-19, like climate change, is a threat multiplier and the challenges it has raised are now indelibly engraved in our vulnerable, interconnected lives. Rather than vainly hoping for a return to an imaginary, erstwhile “normal” what we need is something more fundamental: a new version of hope that embraces a courage to learn what we need to do, to enable us to live a future to which we aspire. Perhaps counter-intuitively, we need to accept that the COVID-19 experience has already changed us deeply and hope that we can learn from this and from the future changes that the pandemic will give rise to. We need to radicalize our responses to the challenges, enabling ourselves to learn new lessons about old but increasingly pertinent topics, such as the realities of human fragility, and inter-connection. (shrink)

Like other Arab countries, Jordan must find ways of responding to the rapid processes of change affecting many aspects of social life. This is particularly urgent in healthcare, where social and technical change is often manifested in tensions about ethical decision-making in the clinic. To explore the attitudes, beliefs and concerns relating to ethical decision-making among health professionals in Jordanian hospitals, a qualitative study was conducted involving face-to-face interviews with medical personnel in four hospitals in Amman, the capital of Jordan. (...) Data were analysed thematically in relation to a pre-existing set of ethical categories. Interviews were conducted with thirty-eight doctors covering most medical specialities. Five major themes emerged from the interviews: ethical awareness, ethical issues, the impact of religion on ethical decision-making, practical and theoretical resources for ethical decision-making, and challenges. While uncertainty was expressed about some aspects of Western approaches to ethics, participants strongly supported adoption of a range of Western bioethical principles, including cultural and ethical diversity, along with adherence to Islamic religious norms. A range of serious ethical challenges facing the Jordanian health system were identified, covering social, legal, managerial, and technical issues. Ethical decision-making in Jordan is complex, having to accommodate the needs of patients, the opinions of doctors and their families, the views of religious authorities, managerial considerations, and both local norms and international standards. Health professionals struggle with three sets of tensions that emerge out of the struggle between traditional, community-embedded forms of social organization and the demands generated by globalization and the influence of Western culture: the tensions between tradition and modernity, conservatism and pragmatism, and religion and secularism. Doctors in Jordan prefer approaches to ethical decision-making that realize a balance between the extremes, although the exact nature of where that balance should lie remains uncertain. (shrink)

The Ebola virus disease epidemic in Western Africa has, in recent months, aroused growing alarm in Western countries. Attention has been drawn to the threat posed to the inhabitants of the region by what has undoubtedly become a major health emergency. As the death toll has mounted, increasingly strident calls for action have been voiced by nongovernmental organizations and international agencies active in the area, such as Médecins Sans Frontières and the World Health Organization and, more recently, even by the (...) U.S. president.Critics of the Western response have claimed that the newfound concern about EVD, which has been present in Africa for nearly 40 years, reflects a longstanding disregard of the needs of people living in the region. They point out that the difficulties in controlling the spread of the disease are in large part due to the lack of effective health infrastructure, which in turn reflects global disparities in wealth and opportunity. Despite the lack of m .. (shrink)