A model for ethical problem solving -- Values in health and illness -- What is the source of moral judgments? -- Benefiting the patient and others : duty to do good and avoid harm -- Justice : allocation of health resources -- Autonomy -- Veracity : honesty with patients -- Fidelity : promise-keeping, loyalty to patients, and impaired professionals -- Avoidance of killing -- Abortion, sterilization, and contraception -- Genetics, birth, and the biological revolution -- Mental health and behavior control (...) -- Confidentiality : ethical disclosure of medical information -- Organ transplants -- Health insurance, health system planning, and rationing -- Experimentation on human subjects -- Consent and the right to refuse treatment -- Death and dying. (shrink)

Every pharmacist, aware or not, is constantly making ethical choices. Sometimes these choices are dramatic, life-and-death decisions, but often they will be more subtle, less conspicuous choices that are nonetheless important. Assisted suicide, conscientious refusal, pain management, equitable and efficacious distribution of drug resources within institutions and managed care plans, confidentiality, and alternative and non-traditional therapies are among the issues that are of unique concern to pharmacists. One way of seeing the implications of such issues and the moral choices they (...) pose is to look at the experiences of practitioners and the kinds of choices they have had to make in situations typically faced by pharmacists. This book is a collection of those situations based on the real experiences of practicing pharmacists. The use of case studies in health care ethics is not new, but in pharmacy it is. This text is an important teaching tool that will help pharmacy students and pharmacists address the increasing number of ethical problems arising in their profession. It is not merely a compilation of cases, but rather is organized for the systematic study of applied ethics. Part I shows how to distinguish ethical problems from other kinds of evaluative judgments and examines the sources of values in pharmacy, posing basic questions about the meaning and justification of ethical claims. Part II explores the basic principles of ethics as they have an impact on pharmacy. Specific cases from clinical settings present in a systematic way the various questions raised by each of the major ethical principles -- benefiting the patient, distributing resources justly, respecting autonomy, dealing honestly with patients, keeping promises of confidentiality, and avoiding harm. Part II examines some of the special problems of contemporary pharmacy such as the linkages between pharmaceutical care and professional practice, human experimentation, reproductive issues, genetic technology, death and dying, and mental health. (shrink)

It is not too great an exaggeration to claim that On the Origin of Species was, along with Das Kapital, one of the two most significant works in the intellectual history of the nineteenth century. As George Henry Lewes wrote in 1868, ‘No work of our time has been so general in its influence’. However, the very generality of the influence of Darwin’s work provides the chief problem for the intellectual historian. Most books and articles on the subject assert the (...) influence but remain very imprecise about its nature. It is very difficult indeed to assess what it was about the Darwinian theory which was so influential and how its influence was felt. This problem in Victorian intellectual history intersects with a related one in the history of science. There has been a tendency on the part of historians of science to isolate Darwin in two related ways. The first is to single him out from the mainstream of nineteenth-century naturalism in Britain and allow ‘Darwinism’ to stand duty for the wider movement of which it was in fact but a part. The second is the tendency to single out his evolutionary theory and to demarcate it sharply from those of his predecessors and contemporaries. According to this interpretation Darwin stood alone as a real, empirical scientist and provided the first genuinely scientific hypothesis for the process by which evolution might have occurred. The theories of the other main evolutionists—Erasmus Darwin, Lamarck, Chambers, Spencer, and Wallace—were more or less besmirched by ideological, anthropomorphic, or other ‘non-scientific’ factors or by the uses to which they were put by their authors. Charles Darwin is thus made to stand out as a figure of comparatively unalloyed scientific status and is treated in relative isolation from the social and intellectual context in which he worked and into which his theory was received. (shrink)

Assesses the ethical problems that doctors face every day and advocates a more universal code of medical ethics, one that draws on the traditions of religion and philosophy.

It is not too great an exaggeration to claim that On the Origin of Species was, along with Das Kapital, one of the two most significant works in the intellectual history of the nineteenth century. As George Henry Lewes wrote in 1868, ‘No work of our time has been so general in its influence’. However, the very generality of the influence of Darwin’s work provides the chief problem for the intellectual historian. Most books and articles on the subject assert the (...) influence but remain very imprecise about its nature. It is very difficult indeed to assess what it was about the Darwinian theory which was so influential and how its influence was felt. This problem in Victorian intellectual history intersects with a related one in the history of science. There has been a tendency on the part of historians of science to isolate Darwin in two related ways. The first is to single him out from the mainstream of nineteenth-century naturalism in Britain and allow ‘Darwinism’ to stand duty for the wider movement of which it was in fact but a part. The second is the tendency to single out his evolutionary theory and to demarcate it sharply from those of his predecessors and contemporaries. According to this interpretation Darwin stood alone as a real, empirical scientist and provided the first genuinely scientific hypothesis for the process by which evolution might have occurred. The theories of the other main evolutionists—Erasmus Darwin, Lamarck, Chambers, Spencer, and Wallace—were more or less besmirched by ideological, anthropomorphic, or other ‘non-scientific’ factors or by the uses to which they were put by their authors. Charles Darwin is thus made to stand out as a figure of comparatively unalloyed scientific status and is treated in relative isolation from the social and intellectual context in which he worked and into which his theory was received. (shrink)

In celebration of the fortieth anniversary of the publication of Beauchamp and Childress’s Principles of Biomedical Ethics, a review is undertaken to compare the lists of principles in various bioethical theories to determine the extent to which the various lists can be reconciled. Included are the single principle theories of utilitarianism, libertarianism, Hippocratism, and the theories of Pellegrino, Engelhardt, The Belmont Report, Beauchamp and Childress, Ross, Veatch, and Gert. We find theories all offering lists of principles numbering from one to (...) ten. Many of the differences can be reconciled, but some critical differences remain. (shrink)

No one really believes that literally all functions of the entire brain must be lost for an individual to be dead. A better definition of death involves a higher brain orientation.

Clinicians cannot obtain valid consent to treatment because they cannot guess which treatment option will serve a particular patient's best interests. These guesses could be made more accurately if patients were paired with providers who share their deep values.

Modern historical criticism of the gospels and Christian origins began in the seventeenth century largely as an attempt to debunk the Christian religion as a pious fraud. The gospels were seen as bits of priestcraft and humbug of a piece with the apocryphal Donation of Constantine. In the few centuries since Reimarus and his critical kin, historical criticism has been embraced and assimilated by many Christian scholars who have seen in it the logical extension of the grammatico-historical method of the (...) Reformers. The new views of New Testament exegesis and of early Christian history are important and well known. Many New Testament scholars would now hold with Schweitzer and Bultmann that Jesus was a preacher of the imminent end of the world. He may have secretly considered himself to be the Messiah, or he may have simply sought to pave the way for another, the apocalyptic Son of Man. After his execution, his disciples' experiences of his resurrection forced on them a conclusion already implicit in his teachings and personal piety: that Jesus was indeed, or had become, the Messiah, and was in fact God's Son. They expected he would soon return as the Son of Man he had predicted. (shrink)

When a new, brain-based definition of death was proposed fifty years ago, no one realized that the issue would remain unresolved for so long. Recently, six new controversies have added to the debate: whether there is a right to refuse apnea testing, which set of criteria should be chosen to measure the death of the brain, how the problem of erroneous testing should be handled, whether any of the current criteria sets accurately measures the death of the brain, whether standard (...) criteria include measurements of all brain functions, and how minorities who reject whole-brain-based definitions should be accommodated. These controversies leave little hope of consensus on how to define death for social and public policy purposes. Rather, there is persistent disagreement among proponents of three major groups of definitions of death: whole-brain, cardiocirculatory or somatic, and higher-brain. Given the persistence and reasonableness of each of these groups of definitions, public policy should permit individuals and their valid surrogates to choose among them. (shrink)

After distinguishing two different meanings of the notion of a morality internal to medicine and considering a hypothetical case of a society that relied on its surgeons to eunuchize priest/cantors to permit them to play an important religious/cultural role, this paper examines three reasons why morality cannot be derived from reflection on the ends of the practice of medicine: (1) there exist many medical roles and these have different ends or purposes, (2) even within any given medical role, there exists (...) multiple, sometimes conflicting ends, and, most critically, (3) the ends of any practice such as medicine must come from outside the practice, that is, from the basic ends or purposes of human living. The paper concludes by considering whether these ends external to medicine are universally part of the moral reality or whether they are socially constructed. The paper argues that, even if various cultural accounts of the common, universal morality are socially constructed, they may, nevertheless, be reflections, however, imperfect, of a more universal common morality that should be thought of as real. Therefore, the morality of medicine must come from a more fundamental morality external to medicine. That external morality will be socially constructed, but may nevertheless reflect an underlying common morality. (shrink)

In its October 2001 issue, this journal published a series of articles questioning the Whole-Brain-based definition of death. Much of the concern focused on whether somatic integration - a commonly understood basis for the whole-brain death view - can survive the brain's death. The present article accepts that there are insurmountable problems with whole-brain death views, but challenges the assumption that loss of somatic integration is the proper basis for pronouncing death. It examines three major themes. First, it accepts the (...) claim of the "disaggregators" that some behaviors traditionally associated with death can be unbundled, but argues that other behaviors (including organ procurement) must continue to be associated. Second, it rejects the claims of the "somaticists," that the integration of the body is critical, arguing instead for equating death with the irreversible loss of "embodied consciousness," that is, the loss of integration of bodily and mental function. Third, it defends higher-brain views against the charge that they are necessarily "mentalist," that is, that they equate death with losing some mental function such as consciousness or personhood. It argues, instead, for the integration of bodily and mental function as the critical feature of human life and that its irreversible loss constitutes death. (shrink)

The dead donor rule (DDR) governs procuring life-prolonging organs. They should be taken only from deceased donors. Miller and Truog have proposed abandoning the rule when patients have decided to forgo life-sustaining treatment and have consented to procurement. Organs could then be procured from living patients, thus killing them by organ procurement. This proposal warrants careful examination. They convincingly argue that current brain or circulatory death pronouncement misidentifies the biologically dead. After arguing convincingly that physicians already cause death by withdrawing (...) treatment, they claim no bright-line differences preclude organ removal from the living. The argument fails for those who accept the double effect doctrine or other grounds for distinguishing forgoing life support from active, intentional killing. If the goal is determining irreversible loss of somatic function, they correctly label current death pronouncement a “legal fiction.” Recognizing a second, public policy meaning of the term death provides grounds for maintaining the DDR without jeopardizing procurement. (shrink)

While twentieth-century medical ethics has focused on the duty of physicians to benefit their patients, the next century will see that duty challenged in three ways. First, we will increasingly recognize that it is unrealistic to expect physicians to be able to determine what will benefit their patients. Either they limit their attention to medical well-being when total well-being is the proper end of the patient or they strive for total well-being, which takes them beyond their expertise. Even within the (...) medical sphere, they have no basis for choosing among the proper medical goals for medicine. Also, there are many plausible strategies for relating predicted benefits to harms, and physicians cannot be expert in picking among these strategies. Second, increasingly plausible ethical systems recognize that in some cases, patient benefit must be sacrificed to protect patient rights including the right to the truth, to have promises kept, to have autonomy respected, and to not be killed. Third, ethics of the next century will increasingly recognize that some patient benefits must be sacrificed to fulfill duties to others - either the duty to serve the interests of others or other duties such as keeping promises, telling the truth, and, particularly, promoting justice. Physicians in the twenty-first century will be seen as having a new, more limited duty to assist the patient in pursuing the patient's understanding of the patient's interest within the constraints of deontological ethical principles and externally imposed duties to promote justice. The result will be a duty to be loyal to the consumer of health care with the recognition that often this will mean that the physician is not permitted to pursue the physician's understanding of the patient's well-being. (shrink)

In Clinical Ethics, Robert Timko argues that the moral dilemmas of clinical medical practice can best be resolved within a framework of prima facie duties, and that the most stringent duty is that of nonmaleficence. Timko shows that respect for individual autonomy and the principle of beneficence are inadequate for the moral practice of medicine since simple adherence to either principle may be insufficient for the provision of "due care.".

The origins of professional ethical codes and oaths are explored. Their legitimacy and usefulness within the profession are questioned and an alternative ethical source is suggested. This source relies on a commonly shared, naturally knowable set of principles known as common morality.

How should we understand the emotional rationality? This first part will explore two models of cognition and analogy strategies, test their intuition about the emotional desire. I distinguish between subjective and objective desire, then presents with a feeling from the "paradigm of drama" export semantics, here our emotional repertoire is acquired all the learned, and our emotions in the form of an object is fixed. It is pretty well in line with the general principles of rationality, especially the lowest reasonable (...) principles. Turned to the second part of this side of reasonable. I will inquire how emotional beliefs, desires, and behaviors contribute to the rationality. I will present a very general biological hypothesis: emotions by controlling highlights the characteristics of perception and reasoning, so that we remove the difficulties due in particular to lead to paralysis; they are being simulated by a simplified perception of information, thus limiting our practice and cognitive choice. How are we to understand emotional or axiological rationality? I pursue analogies with both the cognitive and the strategic models, testing them against intuitions about emotional desires. We distinguish two different classes of desires, the subjective and the objective, and propose that emotions have a semantics that derives from "paradigmatic scenarios", in terms of which our emotional repertoire is learned and the formal objects of our emotions fixed. This fits in well with emerging facts about how our emotional capacities develop, and it can also be squared with the general principles of rationality, particularly minimal rationality. In the second part, I return to the perspective of rationality. I ask how emotions contribute to the rationality of beliefs, desires, and behavior. I proffer a very general biological hypothesis: Emotions spare us the paralysis potentially induced by a particular predicament by controlling the salience of features of perception and reasoning; they temporarily mimic the informational encapsulation of perception and so circumscribe our practical and cognitive options. (shrink)

The current definition of death used for donation after cardiac death relies on a determination of the irreversible cessation of the cardiac function. Although this criterion can be compatible with transplantation of most organs, it is not compatible with heart transplantation since heart transplants by definition involve the resuscitation of the supposedly "irreversibly" stopped heart. Subsequently, the definition of "irreversible" has been altered so as to permit heart transplantation in some circumstances, but this is unsatisfactory. There are three available strategies (...) for solving this "irreversibility problem": altering the definition of death so as to rely on circulatory irreversibility, rather than cardiac; defining death strictly on the basis of brain death (either whole-brain or more pragmatically some higher brain criteria); or redefining death in traditional terms and simultaneously legalizing some limited instances of medical killing to procure viable hearts. The first two strategies are the most ethically justifiable and practical. (shrink)

Our primary focus is on analysis of the concept of voluntariness, with a secondary focus on the implications of our analysis for the concept and the requirements of voluntary informed consent. We propose that two necessary and jointly sufficient conditions must be satisfied for an action to be voluntary: intentionality, and substantial freedom from controlling influences. We reject authenticity as a necessary condition of voluntary action, and we note that constraining situations may or may not undermine voluntariness, depending on the (...) circumstances and the psychological capacities of agents. We compare and evaluate several accounts of voluntariness and argue that our view, unlike other treatments in bioethics, is not a value-laden theory. We also discuss the empirical assessment of individuals? perceptions of the degrees of noncontrol and self-control. We propose use of a particular Decision Making Control Instrument. Empirical research using this instrument can provide data that will help establish appropriate policies and procedures for obtaining voluntary consent to research. (shrink)

The puzzling case of the broken arm -- Hernias, diets, and drugs -- Why physicians cannot know what will benefit patients -- Sacrificing patient benefit to protect patient rights -- Societal interests and duties to others -- The new, limited, twenty-first-century role for physicians as patient assistants -- Abandoning modern medical concepts: doctor's "orders" and hospital "discharge" -- Medicine can't "indicate": so why do we talk that way? --"Treatments of choice" and "medical necessity": who is fooling whom? -- Abandoning informed (...) consent -- Why physicians get it wrong and the alternatives to consent: patient choice and deep value pairing -- The end of prescribing: why prescription writing is irrational -- The alternatives to prescribing -- Are fat people overweight? -- Beyond prettiness: death, disease, and being fat -- Universal but varied health insurance: only separate is equal -- Health insurance: the case for multiple lists -- Why hospice care should not be a part of ideal health care I: the history of the hospice -- Why hospice care should not be a part of ideal health care II: hospice in a postmodern era -- Randomized human experimentation: the modern dilemma -- Randomized human experimentation: a proposal for the new medicine -- Clinical practice guidelines and why they are wrong -- Outcomes research and how values sneak into finding of fact -- The consensus of medical experts and why it is wrong so often. (shrink)