Culture, health, and medicine intersect in various ways—and not always without friction. This paper examines how liberal multicultural states ought to interact with diverse communities which hold different health-related or medical beliefs and practices. The debate is fierce within the fields of medicine and bioethics as to how traditional medicines ought to be regarded. What this debate often misses is the relationship that medical traditions have with cultural identity and the value that these traditions can have beyond the (...) confines of the clinical setting. This paper will attempt to bring some clarity to the discussion. In so doing, it will delve into some controversial areas: (1) the debate around whether liberal states ought to embrace multiculturalism, (2) the existence and nature of group-differentiated rights, (3) the question of whether healthcare systems ought to embrace medical pluralism, and (4) what this would entail for policymakers, clinicians, and patients. Ultimately, I argue that liberal democratic states with multicultural populations ought to recognize medical pluralism as a matter of respecting group-differentiated and individual human rights. (shrink)

This article discusses ethnoveterinary medical pluralism in Western Kenya. Qualitative methods of data collection such as key informant interviews, open-ended in-depth interviews, focus group discussions (FGDs), narratives, and participant and direct observations were applied. The study shows that farmers in Nyang’oma seek both curative and preventive medical services for their animals from the broad range of health care providers available to them within a pluralistic medical system. Kleinman’s model of medical pluralism, which describes the (...) professional, folk, and popular sectors, informs this discussion because of its relevance and appropriateness to the study. It is, however, important to note the overlap in the three sectors and to point out that livestock farmers engage in multiple “consultations” based on a combination of their own characteristics and the cost, availability and specialization of health care providers. The study concludes by recognizing the complexity of ethnoveterinary medical pluralism and calls for the integration of a pluralistic perspective into the planning and implementation of animal health care interventions and services. (shrink)

Explanatory pluralism is the view that the best form and level of explanation depends on the kind of question one seeks to answer by the explanation, and that in order to answer all questions in the best way possible, we need more than one form and level of explanation. In the first part of this article, we argue that explanatory pluralism holds for the medical sciences, at least in theory. However, in the second part of the article (...) we show that medical research and practice is actually not fully and truly explanatory pluralist yet. Although the literature demonstrates a slowly growing interest in non-reductive explanations in medicine, the dominant approach in medicine is still methodologically reductionist. This implies that non-reductive explanations often do not get the attention they deserve. We argue that the field of medicine could benefit greatly by reconsidering its reductive tendencies and becoming fully and truly explanatory pluralist. Nonetheless, trying to achieve the right balance in the search for and application of reductive and non-reductive explanations will in any case be a difficult exercise. (shrink)

Some problems that arise in the account given by Thomasma and Pellegrino [6] of the foundations of medical ethics in a philosophy of medicine are addressed, in particular questions of a conceptual character about treating therelatum of medicine as health. Which concept of health is appropriate and which will bear the burden of the position thomasma and Pellegrino advance? It is argued that the proper relationship of medicine is one between a healer and developing embodied minds. As a consequence, (...) the project of providing a univocal account of the nature of medicine fails. Instead, pluralism infects philosophy and medicine, resulting in different philosophies of medicine. From these philosophies of medicine will follow not a single medical ethics but a variety. (shrink)

Volume 20, Issue 9, September 2020, Page 39-41.

The Truth and Reconciliation Commission of Canada made it clear that understanding the historical, social, cultural, and political landscape that shapes the relationships between Indigenous peoples and social institutions, including the health care system, is crucial to achieving social justice. How to translate this recognition into more equitable health policy and practice remains a challenge. In particular, there is limited understanding of ways to respond to situations in which conventional practices mandated by the state and regulated by its legal apparatus (...) come into direct conflict with the values and autonomy of Indigenous individuals, communities, and nations. In this paper, we consider two cases of conflict between Indigenous and biomedical perspectives to clarify some of the competing values. We argue for the importance of person‐ and people‐centered approaches to health care. These value conflicts must be understood at multiple levels to clarify their personal, social, cultural, and political dimensions. Taking into account the divergence between epistemic cultures and communities allows us to understand the multiple narratives deployed in decision‐making processes in clinical, community, and juridical contexts. Recognizing the knowledge claims of Indigenous peoples in health care can help clinicians avoid reinforcing the divides created by the structural and institutional legacy of colonialism. This analysis also provides ways to adjudicate conflicts in health care decision‐making by disentangling cultural, political, medical, and pragmatic issues to allow for respectful dialogue. Insofar as the engagement with cultural pluralism in health care rights is conducted with reciprocal recognition, the medical community and Indigenous peoples can address together the difficult question of how to integrate different epistemic cultures in the health care system. (shrink)

Medical Professionals: Conflicts and Quandaries in Medical Practice offers a fresh approach to understanding the role-related conflicts and quandaries that pervade contemporary medical practice. While a focus on professional conflicts is not new in the literature, what is missing is a volume that delves into medical professionals' own experience of the conflicts and quandaries they face, often as a result of inhabiting multiple roles. The volume explores the ways in which these conflicts and quandaries are exacerbated (...) by broader societal forces, including changing scientific and technological paradigms, commercialization, and strengthened consumer movements, which simultaneously expand the scope of roles and responsibilities that medical professionals are expected to fulfill, and make it more difficult to do so. Several empirical chapters analyze data from qualitative interview studies with clinicians and other stakeholders. The studies highlight the burdens on clinicians who are expected to make informed and justified judgments and decisions in the midst of competing pressures; authors describe the methods that clinicians use to address the associated tensions within specific contexts. Two conceptual chapters follow and offer some innovative ways to think about the challenges facing medical professionals as they strive to make sense of the changing landscape within healthcare. The first reflects on the challenges to clinical practice in the midst of shifting and often competing definitions of disease and associated ideologies of care. The second reflects more broadly on the utility of value pluralism as a framework for conceptualizing and working through moral and professional quandaries. The book concludes with a chapter containing suggestions for how members of the medical profession might reframe their thinking about their roles, responsibilities, and decision-making in the midst of inevitable quandaries such as those presented here. This book will be of vital reading for academics, researchers, educators, postgraduate students, and interested health care practitioners and administrators. (shrink)

How is medical knowledge made? There have been radical changes in recent decades, through new methods such as consensus conferences, evidence-based medicine, translational medicine, and narrative medicine. Miriam Solomon explores their origins, aims, and epistemic strengths and weaknesses; and she offers a pluralistic approach for the future.

High-dose chemotherapy and autologous stem cell transplantation is used to treat some advanced malignancies. It is a traumatic procedure, with a high complication rate and significant mortality. ASCT patients and their carers draw on many sources of information as they seek to understand the procedure and its consequences. Some seek information from beyond orthodox medicine. Alternative beliefs and practices may conflict with conventional understanding of the theory and practice of ASCT, and ‘contested understandings’ might interfere with patient adherence to the (...) strict and demanding protocols required for successful ASCT.The present study, conducted in Sydney, Australia, examines narrative-style interviews with 10 sequentially recruited ASCT patients and nine of their carers conducted at the time of transplant and three months later. Transcripts were read for instances of mention of alternative advice, and for instances of contested understanding of information relevant to the transplant.Patients and carer pairs expressed closely concordant views about alternative advice. Five pairs were consulting alternative practitioners. Contested understanding was expressed in four domains—understandings of the transplant itself and its underlying theory, of the relationship between the components of the ‘transplant’, of the nature and role of stem cells, and of beliefs about bodily function and life-style. Contested understandings of the transplant treatment were expressed as predominantly personal interpretations of orthodox informationPatients and carers seemed to recognise that alternative and conventional systems were discordant, yet they were able to separate the two, and adhere to each practice without prejudicing their medical treatment. A single case of late, post-transplant repudiation of Western medicine is discussed to emphasise some of the possible determinants of dissonance when it does occur. (shrink)

ABSTRACTModern medical practice is becoming increasingly pluralistic and diverse. Hence, cultural competency and awareness are given more focus in physician training seminars and within medical school curricula. A renewed interest in describing the varied ethical constructs of specific populations has taken place within medical literature. This paper aims to provide an overview of Islamic Medical Ethics. Beginning with a definition of Islamic Medical Ethics, the reader will be introduced to the scope of Islamic Medical (...) Ethics literature, from that aimed at developing moral character to writings grounded in Islamic law. In the latter form, there is an attempt to derive an Islamic perspective on bioethical issues such as abortion, gender relations within the patient‐doctor relationship, end‐of‐life care and euthanasia. It is hoped that the insights gained will aid both clinicians and ethicists to better understand the Islamic paradigm of medical ethics and thereby positively affect patient care. (shrink)

Medicalization was the theme of the 29th European Conference on Philosophy of Medicine and Health Care that included a panel session on the DSM and mental health. Philosophical critiques of the medical model in psychiatry suffer from endemic assumptions that fail to acknowledge the real world challenges of psychiatric nosology. The descriptive model of classification of the DSM 3-5 serves a valid purpose in the absence of known etiologies for the majority of psychiatric conditions. However, a consequence of the (...) “atheoretical” approach of the DSM is rampant epistemological confusion, a shortcoming that can be ameliorated by importing perspectives from the work of Jaspers and McHugh. Finally, contemporary psychiatry’s over-reliance on neuroscience and pharmacotherapy has led to a reductionist agenda that is antagonistic to the inherently pluralistic nature of psychiatry. As a result, the field has suffered a loss of knowledge that may be difficult to recover. (shrink)

This paper is a critique of ‘integrative medicine’ as an ideal of medical progress on the grounds that it fails to realise the cognitive value of alternative medicine. After a brief account of the cognitive value of alternative medicine, I outline the form of ‘integrative medicine’ defended by the late Stephen Straus, former director of the US National Centre for Complementary and Alternative Medicine. Straus’ account is then considered in the light of Zuzana Parusnikova’s recent criticism of ‘integrative medicine’ (...) and her distinction between ‘cognitive’ and ‘opportunistic’ engagement with alternative medicine. Parusnikova warns that the medical establishment is guilty of ‘dogmatism’ and proposes that one can usefully invoke Karl Popper’s ‘critical rationalism’ as an antidote. Using the example of Straus, I argue that an appeal to Popper is insufficient, on the grounds that ‘integrative medicine’ can class as a form of cognitively-productive, critical engagement. I suggest that Parusnikova’s appeal to Popper should be augmented with Paul Feyerabend’s emphasis upon the role of ‘radical alternatives’ in maximising criticism. ‘Integrative medicine’ fails to maximise criticism because it ‘translates’ alternative medicine into the theories and terminology of allopathic medicine and so erodes its capacity to provide cognitively-valuable ‘radical alternatives’. These claims are then illustrated with a discussion of ‘traditional’ and ‘medical’ acupuncture. I conclude that ‘integrative medicine’ fails to exploit the cognitive value of alternative medicine and so should be rejected as an ideal of medical progress. (shrink)

ABSTRACT In considering the hopeful rhetoric that pervades the “nothing but” psychopharmacological approaches to depression—a contemporary version of what William James calls medical materialism—this article argues that only a thorough-going pluralist account of hope is a hope worth wanting. Medical materialist hope is better conceptualized as a variation of optimism, which assumes a single universe that is already the best of all possible universes, and thereby only promotes optimization of the status quo, rather than encourage a wider undertaking (...) of a variety of experiments in living. A pluralist hope, as opposed to optimism, cannot logically infer what the future will bring from a reigning scientific model of the brain. Rather, a pluralist hope is a passionate belief that a not-yet unimagined, and therefore indeterminate, future will meliorate current human ills should humans strenuously work toward achieving it. (shrink)

The role of physicians in armed conflict -- International humanitarian law -- International criminal law -- Customary status of international humanitarian law -- The relevant human rights norms applicable to the work of physicians in armed conflict -- The interpretation of the reference to medical ethics and generally accepted medical standards pursuant to the Vienna Convention on the Law of Treaties -- Medical ethics in international law -- A pluralistic approach to medical ethics -- The documents (...) by the World Medical Association (WMA) -- Conclusion, recommendations and outlook. (shrink)

ABSTRACT Modern medical practice is becoming increasingly pluralistic and diverse. Hence, cultural competency and awareness are given more focus in physician training seminars and within medical school curricula. A renewed interest in describing the varied ethical constructs of specific populations has taken place within medical literature. This paper aims to provide an overview of Islamic Medical Ethics. Beginning with a definition of Islamic Medical Ethics, the reader will be introduced to the scope of Islamic (...) class='Hi'>Medical Ethics literature, from that aimed at developing moral character to writings grounded in Islamic law. In the latter form, there is an attempt to derive an Islamic perspective on bioethical issues such as abortion, gender relations within the patient‐doctor relationship, end‐of‐life care and euthanasia. It is hoped that the insights gained will aid both clinicians and ethicists to better understand the Islamic paradigm of medical ethics and thereby positively affect patient care. (shrink)

In current philosophical discussions on evidence in the medical sciences, epidemiology has been used to exemplify a specific version of evidential pluralism. According to this view, known as the Russo–Williamson Thesis, evidence of both difference-making and mechanisms is produced to make causal claims in the health sciences. In this paper, I present an analysis of data and evidence in epidemiological practice, with a special focus on research on the exposome, and I cast doubt on the extent to which (...) evidential pluralism holds in this case. I start by focusing on the claim that molecular data allows for the production of mechanistic evidence. On the basis of a close look at the ways in which molecular data is used in exposome research, I caution against interpretations in terms of mechanistic evidence. Secondly, I expand my critical remarks on the thesis by addressing the conditions under which data is categorised as evidence in exposome research. I argue that these show that the classification of a dataset as a type of evidence is dependent on the ways in which the data is used. This is in contrast with the approach of evidential pluralism, where evidence is classified in different types on the basis of its intrinsic properties. Finally, I come back to what I consider the core of the thesis and suggest that the epidemiological research analysed in the paper indicates different interpretations of evidential pluralism and its applicability in the health sciences. (shrink)

Meynell’s contention is that feminists should attend to pictures in science as distinctive bearers of epistemic content that cannot be reduced to propositions. Remarks on the practice and function of medical illustration—specifically, images Nancy Tuana used in her discussion of the construction of ignorance of women’s sexual function (2004)—show pictures to be complex and powerful epistemic devices. Their affinity with perennial feminist concerns, the relation between epistemic subject and object, and the nature of social knowledge, are of particular interest.

Christian Scientists' refusal of medical care for their children illustrates the kind of conflict over moral and practical authority that can arise between groups in a pluralistic society. While consensus may not be possible, changes in the way both groups socialize members may allow the medical and Christian Science communities to achieve a compromise that is respectful to both.

As medical technology has advanced, the question of medical futility has become a topic of intense debate both within the medical community and within society as a whole. However, a unanimous definition thereof is yet to be decided—some commentators are sceptical as to whether an agreement will ever be reached—and this continues to lead to difficulties, tension, and even legal action when a treating physician disagrees with a patient and/or a patient’s family regarding care and treatment options. (...) Although living in a pluralistic society presents one of the major reasons as to why, despite 30 years of intense discussion, no consensus has been made; the issue of medical futility will always be complex as it is, by nature, multifaceted, and numerous elements—including possible risks, evidence of the probability of benefit, the wishes of the patient (and family), professional standards, and cost—interact. Nevertheless, the global medical community has seen the development of two distinctly different approaches to medical futility: one in which the autonomy of patients is of paramount importance in the decision whether or not to pursue a treatment; and one in which beneficence and primum non nocere—first do no harm—are almost entirely the clinician’s prerogative, and whereby he/she has a duty to refuse any treatment for which the potential risks outweigh the potential benefits for the patient. Recently, however, there has been a rejection of this dichotomous view of medical futility and the apparent “power struggle” between physician and patient, and a positive movement towards a more collaborative decision-making process that highlights the necessity of communication, aiming to result in the obtainment of the best possible outcome for each patient as an individual. (shrink)

Gender-medicine has been very successful in discovering gaps in medical knowledge, disclosing biases in earlier research, and generating new results. It has superseded a more androcentric and sexist medicine. Yet, its development should not be understood in terms of a further approximation of value-freedom. Rather, it is a case of better value-laden science due to an enhanced pluralism in medicine and society. This interpretation is based on an account of the origins of gender-medicine in the feminist women’s health (...) movement and an analysis of the debate on inclusion of women in clinical trials. Consequently, the history of gender-medicine provides support for a procedural account of objectivity that stresses the importance of a diversity of perspectives. (shrink)

Increasing European co-operation must take place in many areas, including medical ethics. Against the background of common cultural norms and pluralistic variation within political traditions, religion and lifestyles, Europe will have to converge towards unity within the field of medical ethics. This article examines how such convergence might develop with respect to four major areas: European research ethics committees, democratic health systems, the human genome project and rules for stopping futile treatments.

For my own work in philosophy of science, I find of utmost importance to exchange ideas with practicing scientists. The author of this book, Peter Rabins, is a medical doctor specializing in psychiatry. With much regret, I have not met Professor Rabins in person yet, but I’m hoping to do so soon, as his recent book The Why of Things: Causality in Science, Medicine, and Life has been a most enjoyable read and source of inspiration. The book constitutes a (...) noteworthy addition to Professor Rabins’ academic production—which has been mainly in the area of medicine and psychiatry—as it goes to the heart of two deep, everlasting philosophical quarrels: causation and explanation.The Why of Things is written with expertise, the expertise of a doctor that devoted time and effort to reflecting upon the philosophical underpinnings of an important aspect of his own profession : how to establish causal relations and to provide causal explanations. This is not a ‘ .. (shrink)

Medical classification systems aim to provide a manageable taxonomy for sorting diagnoses into their proper classes. The question, this paper wants to critically examine, is how to correctly systematise diseases within classification systems that are applied in a variety of different settings. ICD and DSM , the two major classification systems in medicine and psychiatry, will be the main subjects of this paper; however, the arguments are not restricted to these classification systems but point out general methodological and epistemological (...) challenges of classifying diseases for differing purposes. Deciding what qualifies as a disease to be included into a classification system as well as choosing a specific validator for correctly systematising diseases is complicated because the broad applicability of medical classification systems simultaneously appears as aim and challenge. Drawing upon the case study of classifying Alzheimer’s disease, this paper will address three dilemmas in designing ‘good’ medical classification systems. They are due to general epistemological problems of medicine, such as the relationship between individual manifestations of diseases and the necessity of building groups in order to scientifically elucidate causes of diseases. Moreover, they involve pragmatic issues of designing usable classifications that allow for easily discriminating between classes of diseases, restricting, however, the completeness of disease representations. This paper wants to trace how the choice of certain validators is unavoidably value-laden and deeply intertwined with epistemological assumptions of how different uses relate to each other, resulting either in a prioritisation of (constrained) coherence or of (vague) pluralistic connectibility. (shrink)

Reproductive tourism is the travelling by candidate service recipients from one institution, jurisdiction, or country where treatment is not available to another institution, jurisdiction, or country where they can obtain the kind of medically assisted reproduction they desire. The more widespread this phenomenon, the louder the call for international measures to stop these movements. Three possible solutions are discussed: internal moral pluralism, coerced conformity, and international harmonisation. The position is defended that allowing reproductive tourism is a form of tolerance (...) that prevents the frontal clash between the majority who imposes its view and the minority who claim to have a moral right to some medical service. Reproductive tourism is moral pluralism realised by moving across legal borders. As such, this pragmatic solution presupposes legal diversity. (shrink)

Christian health care professionals in our secular and pluralistic society often face uncertainty about the place religious faith holds in today's medical practice. Through an examination of a virtue-based ethics, this book proposes a theological view of medical ethics that helps the Christian physician reconcile faith, reason, and professional duty. Edmund D. Pellegrino and David C. Thomasma trace the history of virtue in moral thought, and they examine current debate about a virtue ethic's place in contemporary bioethics. Their (...) proposal balances theological ethics, based on the virtues of faith, hope, and charity, with contemporary medical ethics, based on the principles of beneficence, justice, and autonomy. The result is a theory of clinical ethics that centers on the virtue of charity and is manifest in practical moral decisions. Using Christian bioethical principles, the authors address today's divisive issues in medicine. For health care providers and all those involved in the fields of ethics and religion, this volume shows how faith and reason can combine to create the best possible healing relationship between health care professional and patient. (shrink)

Increasingly, physicians are being asked to provide technical services that many believe are morally wrong or inconsistent with their beliefs about the meaning and purposes of medicine. This controversy has sparked persistent debate over whether practitioners should be permitted to decline participation in a variety of legal practices, most notably physician-assisted suicide and abortion. These debates have become heavily politicized, and some of the key words and phrases are being used without a clear understanding of their meaning. In this essay, (...) I endeavor, firstly, to clarify the meaning of some of these terms: conscience, conscientious action, professional judgment, conscientious objection, conscience clauses, civil disobedience, and tolerance. I argue that use of the term conscientious objection to describe these refusals by health care professionals is mistaken and confusing. Secondly, relying on a proper understanding of the moral and technical character of medical judgment, the optimal deference that the state and markets ought to have toward professions, and general principles of Lockean tolerance for a diversity of practices and persons in a flourishing, pluralistic, democratic society, I offer a defense of tolerance with respect to the deeply held convictions of physicians and other health care professionals who hold minority views on contested but legal medical practices. (shrink)

Democratic societies that separate church and state face major challenges in accommodating religious convictions. This applies especially to determining healthcare policies. Building on our prior work on the demands and limits of religious accommodation in democratic societies, we propose a set of ethical standards that can guide societies in meeting this challenge. In applying and defending these standards, we explore three topics: vaccine resistance, abortion, and concerns about rights to healthcare. We clarify these and other issues of religious accommodation and (...) propose ethical standards for approaching these and other problems. (shrink)

"When it comes to morality as it is practiced in medicine, Brody makes clear that the ethical issues are never as simple as black and white - that there are myriad factors and fine nuances that can and should challenge decision making as it is commonly practiced in difficult medical cases. In this collection, delving thoughtfully and systematically into methodology, research ethics, clinical ethics, and Jewish medical ethics, he tackles thorny life-and-death questions head-on and fearlessly. He casts a (...) light into all the corners of end-of-life decisions - a field in which he has exemplary credentials - while illuminating a new understanding of morality and ethics." "The introduction outlines much of Brody's approach, defines the terminology used, and contrasts his ethical positions with much of the competing literature, Taking Issue will be invaluable to students and scholars in medical ethics, bioethics, and the philosophy of medicine." "Baruch A. Brody is the Leon Jaworski Professor Biomedical Ethics and director of the Center for Medical Ethics and Health Policy at Baylor College of Medicine. He is also a professor of philosophy at Rice University and director of the Ethics program at the Methodist Hospital."--BOOK JACKET. (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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Clinical guidelines summarise available evidence on medical treatment, and provide recommendations about the most effective and cost-effective options for patients with a given condition. However, sometimes patients do not desire the best available treatment. Should doctors in a publicly-funded healthcare system ever provide sub-optimal medical treatment? On one view, it would be wrong to do so, since this would violate the ethical principle of beneficence, and predictably lead to harm for patients. It would also, potentially, be a misuse (...) of finite health resources. In this paper, we argue in favour of permitting sub-optimal choices on the basis of value pluralism, uncertainty, patient autonomy and responsibility. There are diverse views about how to evaluate treatment options, and patients’ right to self-determination and taking responsibility for their own lives should be respected. We introduce the concept of cost-equivalence, as a way of defining the boundaries of permissible pluralism in publicly-funded healthcare systems. As well as providing the most effective, available treatment for a given condition, publicly-funded healthcare systems should provide reasonable suboptimal medical treatments that are equivalent in cost to the optimal treatment. We identify four forms of cost-equivalence, and assess the implications of CE for decision-making. We evaluate and reject counterarguments to CE. Finally, we assess the relevance of CE for other treatment decisions including requests for potentially superior treatment. (shrink)

The Hippocratic ethic, or medical ethics, has guided medical practitioners for 2,500 years. More recently it has been displaced by bioethics. Traditional medicalethics is a covenant between a competent physician and a sick patient, the purpose of which is to effect healing. Bioethics is a civil consensual ethic regulating health-care delivery. It is not personal by nature.Medical ethics is a deontological, virtue-based ethic. Bioethics, particularly as expressed in principlism, its most prominent school in the United States, isa (...) liberal utilitarian ethic that emphasizes individual autonomy.Bioethics and principlism both play a role in guiding health-care delivery in a pluralistic society. However, traditional medical ethics, and not bioethics, bestaddresses the moral issues arising in the personal relationships between a treating physician and a suffering patient. (shrink)

At the center of medical morality is the healing relationship. It is defined by three phenomena: the fact of illness, the act of profession, and the act of medicine. The first puts the patient in a vulnerable and dependent position; it results in an unequal relationship. The second implies a promise to help. The third involves those actions that will lead to a medically competent healing decision. But it must also be good for the patient in the fullest possible (...) sense. The physician cannot fully heal without giving the patient an understanding of alternatives such that he or she can freely arrive—together with the physician—at a decision in keeping with his or her personal morality and values. In today's pluralistic society, universal agreement on moral issues between physicians and patients is no longer possible. Nevertheless, a reconstruction of professional ethics based on a new appreciation of what makes for a true healing relationship between patient and physician is both possible and necessary. (shrink)

I would like to begin by thanking all of the commentators for their insightful analyses of ‘Genetic information, insurance and a pluralistic approach to justice’; I learnt a great deal from them all. Naturally, I cannot do justice to all of their criticisms in this brief response; instead, I shall use their remarks to prompt some clarificatory points about my arguments in the hope that this will help readers to draw their own conclusions about the various points of disagreement. My (...) aim in the paper was modest; I aimed to argue that considerations of justice do not speak unequivocally against the use of Genetic Test Results (GTRs) in insurance, and that a pluralist approach may lend support to some limited uses. This represents a compromise position between outright prohibition, and using GTRs in an insurance market in accordance with purely commercial principles. Notably, this conclusion is compatible with the thought that there may be other very strong moral reasons in favour of prohibition. These include concerns about privacy, as well as the consequentialist and human rights considerations that Tiller and Delatycki rightly highlight.1 Of course, considerations of justice are not orthogonal to questions regarding the right against genetic discrimination, since such a right might plausibly be supported by appeal to broadly egalitarian considerations. Indeed, one important challenge for the rights-based argument for prohibition is to defend the strong degree of genetic exceptionalism it connotes. As I briefly suggested in the paper, broadly egalitarian arguments might be invoked in an attempt to justify at least some degree of genetic exceptionalism here. Notably though, in her commentary, Feiring expresses scepticism about the view of genetic exceptionalism that is implicit in my acceptance of the idea that the use of GTRs in insurance warrants its own specific guidance.2 Given the different …. (shrink)

I defend an empirically-oriented approach to the analysis and remediation of social injustice. My springboard for this argument is a debate—principally represented here between Tommie Shelby and Elizabeth Anderson, but with much deeper historical roots and many flowering branches—about whether racial-justice advocacy should prioritize integration (bringing different groups together) or community development (building wealth and political power within the black community). Although I incline toward something closer to Shelby’s “egalitarian pluralist” approach over Anderson’s single-minded emphasis on integration, many of Shelby’s (...) criticisms of integrationism are misguided, and his handling of the empirical literature is profoundly unbalanced. In fact, while both Shelby and Anderson defend the importance of social science to their projects, I’ll argue that each takes a decidedly unempirical approach, which ultimately obscures the full extent of our ignorance about what we can and ought to do going forward. A more authentically empirical tack would be more epistemically humble, more holistic, and less organized around what I’ll call prematurely formulated “Grand Unified Theories of Social Change.” I defend a more “diversified experimentalist” approach, which rigorously tests an array of smaller-scale interventions before trying to replicate and scale up the most promising results. (shrink)

In his recent book The Foundation of Bioethics , H. Tristam Engelhardt Jr. advances the idea of a peaceable pluralist moral society based on principles of autonomy, beneficience, and ownership. This paper tries to show that unless there is one and only one rationally sustainable definition of "a person", then the peaceable society cannot remain peaceable, but will be stirred up by groups with different and equally rational definitions. The paper further tries to show that Engelhardt's own definition of "a (...) persons in the strict sense" is an unsatisfactory solution to the problem, and the same is true for any of the possible compromises. Keywords: medical ethics, persons, autonomy CiteULike Connotea Del.icio.us What's this? (shrink)

Despite the central place of suffering in medical care, suffering in infants and nonverbal children remains poorly defined. There are epistemic problems in the detection and treatment of suffering in infants and normative problems in determining what is in their best interests. A lack of agreement on definitions of infant suffering leads to misunderstanding, mistrust, and even conflict amongst clinicians and parents. It also allows biases around intensive care and disability to affect medical decision-making on behalf of infants. (...) In this paper, I propose the concept of suffering pluralism, which is a novel multidimensional view of infant suffering based on subjective and objective components. The concept of suffering pluralism is more inclusive of the multiple ways in which infant suffering can occur. It acknowledges and defines a subjective component to infant suffering, while also focusing moral attention on objective well-being by describing it using the language of suffering. This concept allows us to better weigh up subjective and objective components of well-being. It also encourages clarity and consistency in claiming suffering, which is likely to improve communication and reduce conflict in medical decision-making for unwell infants and children. I will end by exploring possible critiques and limitations of this concept. (shrink)

At the center of medical morality is the healing relationship. It is defined by three phenomena: the fact of illness, the act of profession, and the act of medicine. The first puts the patient in a vulnerable and dependent position; it results in an unequal relationship. The second implies a promise to help. The third involves those actions that will lead to a medically competent healing decision. But it must also be good for the patient in the fullest possible (...) sense. The physician cannot fully heal without giving the patient an understanding of alternatives such that he or she can freely arrive—together with the physician—at a decision in keeping with his or her personal morality and values. In today's pluralistic society, universal agreement on moral issues between physicians and patients is no longer possible. Nevertheless, a reconstruction of professional ethics based on a new appreciation of what makes for a true healing relationship between patient and physician is both possible and necessary. (shrink)

In the paper ‘Genetic information, insurance, and a pluralistic approach to justice’, Jonathan Pugh1 develops an argument from unresolved pluralism in our theories of justice, via the pluralism this occasions in relation to the specific question of the use of genetic test results in insurance underwriting, to the conclusion that the UK regulatory approach in relation to the use of GTRs in insurance is broadly correct.1 Pugh’s argument is wide-ranging and I cannot provide a complete critique of it (...) in this short comment, but I will gesture towards some strands of the argument that are potentially problematic. The first potential problem in the argument is that Pugh bases his argument on a very extensive range of accounts of justice, including pure maximising consequentialism, strict egalitarianism and libertarianism, among many others. If these are all accounts of justice, it is not strange that there is pluralism of conclusions in relation to a specific question of justice or discrimination, such as the use of GTRs in the underwriting of specific kinds of insurance contracts. Pugh’s range, for instance, includes accounts of justice that deny the direct importance of distributive concerns as well as accounts that see distributive concerns as crucial. These accounts disagree not only about the answer to Pugh’s question but also about …. (shrink)

Education, medicine and psychotherapeutics offer exemplary sites through which liberty and its dreams are realized. This article explores the social history of medical freedom and liberty in North America during the late nineteenth and early twentieth centuries. The National League for Medical Freedom (NLMF) and the American Medical Liberty League (AMLL) offered fierce resistance to allopathic power. Allopatic liberties and rights to medical practice in asylums, clinics, courts, hospitals, prisons and schools were never certain. The politics (...) of these liberties and rights represents a fascinating story that neither intellectual nor social historians have fully appreciated. (shrink)

Teaching medical ethics to medical students in a pluralistic society is a challenging task. Teachers of ethics have obligations not just to teach the subject matter but to help create an academic environment in which well motivated students have reinforcement of their inherent good qualities. Emphasis should be placed on the ethical aspects of daily medical practice and not just on the dramatic dilemmas raised by modern technology. Interdisciplinary teaching should be encouraged and teaching should span the (...) entire duration of medical studies. Attention should be paid particularly to ethical problems faced by the students themselves, preferably at the time when the problems are most on the students' minds. A high level of academic demands, including critical examination of students' progress is recommended. Finally, personal humility on the part of teachers can help set a good example for students to follow. (shrink)

In today’s pluralistic society, clinical ethics consultation cannot count on a pre-given set of rules and principles to be applied to a specific situation, because such an approach would deny the existence of different and divergent backgrounds by imposing a dogmatic and transcultural morality. Clinical ethics support (CES) needs to overcome this lack of foundations and conjugate the respect for the difference at stake with the necessity to find shared and workable solutions for ethical issues encountered in clinical practice. We (...) argue that a pragmatist approach to CES, based on the philosophical theories of William James, John Dewey, and Charles Sanders Peirce, can help to achieve the goal of reaching practical solutions for moral problems in the context of today’s clinical environment, characterized by ethical pluralism. In this article, we outline a pragmatist theoretical framework for CES. Furthermore, we will show that moral case deliberation, making use of the dilemma method, can be regarded an example of a pragmatist approach to CES. (shrink)

The legacy of colonial rule has permeated into all aspects of life and contributed to healthcare inequity. In response to the increased interest in social justice, medical educators are thinking of ways to decolonise education and produce doctors who can meet the complex needs of diverse populations. This paper aims to explore decolonising ideas of healing within medical education following recent events including the University College London Medical School’s Decolonising the Medical Curriculum public engagement event, the (...) Wellcome Collection ’s Ayurvedic Man: Encounters with Indian Medicine exhibition and its symposium on Decolonising Health, SOAS University of London’s Applying a Decolonial Lens to Research Structures, Norms and Practices in Higher Education Institutions and University College London Anthropology Department’s Flourishing Diversity Series. We investigate implications of ‘recentring’ displaced indigenous healing systems, medical pluralism and highlight the concept of cultural humility in medical training, which while challenging, may benefit patients. From a global health perspective, climate change debates and associated civil protests around the issues resonate with indigenous ideas of planetary health, which focus on the harmonious interconnection of the planet, the environment and human beings. Finally, we look further at its implications in clinical practice, addressing the background of inequality in healthcare among the BAME populations, intersectionality and an increasing recognition of the role of inter-generational trauma originating from the legacy of slavery. By analysing these theories and conversations that challenge the biomedical view of health, we conclude that encouraging healthcare educators and professionals to adopt a ‘ decolonising attitude ’ can address the complex power imbalances in health and further improve person-centred care. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Morality in Flux: Medical Ethics Dilemmas in the People's Republic of ChinaRen-Zong Qiu (bio)IntroductionModern China is undergoing a fundamental change from a monolithic society to a rather pluralistic one. It is a long and winding road. Marxism is facing various challenges as the influence of Western culture increases. Confucianism is still deeply entrenched in the Chinese mind but various religions, including Buddhism, Islam, and Christianity are experiencing a (...) revival. Almost fifty minorities coexist in the country in addition to the majority Han people. Tension and conflict are inevitable as diverse—and sometimes incompatible—values come to the fore at this historic juncture. Many fields, including medicine, face new challenges, and in this environment the field of bioethics is flourishing.Like many countries, China is groping with the effects of new medical technology and skyrocketing health care costs. But in the context of the Chinese sociocultural environment, some unique—as well as more familiar—issues arise. None of the classic texts provide ready-made answers to these dilemmas; we must find the answers ourselves. The only reasonable way to resolve the conflicts between opposing values is through dialogue, consultation, and negotiation among the various social and cultural groups.The bioethical dilemmas receiving the most attention in China now relate to the two ends of life: birth and death. On one end are issues relating to reproductive technology, especially birth control and family planning; at the other end is euthanasia.Dilemmas Surrounding Reproductive TechnologyAccording to traditional Chinese belief, not having a child results from not having virtue. In fact, the most serious violation of the Confucian [End Page 16]principle of filial piety is to be without offspring. A Chinese man without a child experiences heavy psychological pressure, and the burden is especially onerous for women because infertility is always blamed on the wife. Wives who do not bear a child are stigmatized and mistreated—even abused—in families that stick to traditional values.In China today, this widely held belief is colliding with another reality: an apparent increase in infertility among newly-married couples. The rate may be about 5 percent. These couples turn to doctors for help.Artificial insemination by donor (AID) and by husband is now widely practiced. Eleven provinces have established sperm banks, and private doctors are performing AID for considerable fees. But procedures to address legal and ethical problems associated with the procedure have lagged behind. With the exception of a few centers in large cities, AID is undertaken without established procedures or policies relating to the selection of donors and recipients, records about those involved, or clarification of the status of the child. The legal status of the child remains unresolved.The status of the child within the community is also unresolved as traditional values clash with the application of modern technology to childbearing. The case of "The Child Who Did Not Belong" (see box), illustrates how an AID child is not accepted by the family that embraces traditional values because he is not the husband's biological child.In vitro fertilization (IVF) is another alternative. Two IVF centers are in operation, one in Beijing and the other in Changsha, and both have succeeded in producing live births. This technology has received considerable media attention and is generally accepted even among those with traditional views.But much of this medical technology is not widely accessible—especially in rural areas—and so some infertile couples resort to surrogate motherhood to ensure an heir. An infertile couple enters into a contract with a woman who has intercourse with the husband in order to bear a child for the couple. This practice is called "borrowing a wife." In some villages, the "borrowed wife" receives as much as 10,000 yuan (five times a professor's monthly salary or about $250) for a girl and double that for a boy.But the more common and thorny problems involved with the beginning of life relate to birth control, family planning, and the "one couple, one child" policy that the Chinese government instituted to curb overpopulation. The goal of that policy is to prevent China's population from exceeding 1.2 billion in the year 2000... (shrink)

Fertility clinicians participate in non-sexual reproductive projects by providing assisted reproductive technology (ART) to those hoping to reproduce, in support of their reproductive goals. In most countries where ART is available, the state regulates ART as a form of medical treatment. The predominant position in the reproductive rights literature frames the clinician’s role as medical technician, and the state as a third party with limited rights to interfere. These roles broadly align with established functions of clinician and state (...) in Western liberal democracies, where doctors have duties to provide safe, beneficial and legal healthcare to all who seek it. Recognised state responsibilities include safeguarding equitable access to medical services and protecting and promoting reproductive liberty.I argue against this normative moral framing of clinician and state involvement in non-sexual reproduction, suggesting that clinician and state join the non-sexual reproductive project at the point of triggering conception. Begetting a child is more than just the provision and regulation of healthcare; it generates rights and confers responsibilities on all who join this morally significant project. All who collaborate have the right to join or refuse to join the project. I suggest this is intuitively understood in the sexual realm, but not in the non-sexual realm. My key substantive claim is that non-sexual reproduction is a pluralist pursuit that morally implicates more than the genetic and gestational contributors. I find that while the moral basis of a clinician or the state’s right to refuse to join the ART project is the same as for those providing gestational or genetic input, the reasons that morally underpin their refusal differs. (shrink)

The determination of death by neurological criteria remains controversial scientifically, culturally, and legally, worldwide. In the United Kingdom, although the determination of death by neurological criteria is not legally codified, the Code of Practice of the Academy of Medical Royal Colleges is customarily used for neurological death determination and treatment withdrawal. Unlike some states in the US, however, there are no provisions under the law requiring accommodation of and respect for residents' religious rights and commitments when secular conceptions of (...) death based on medical codes and practices conflict with a traditional concept well-grounded in religious and cultural values and practices. In this article, we analyse the medical, ethical, and legal issues that were generated by the recent judgement of the High Court of England and Wales in Re: A [2015] EWHC 443. Mechanical ventilation was withdrawn in this case despite parental religious objection to a determination of death based on the code of practice. We outline contemporary evidence that has refuted the reliability of tests of brainstem function to ascertain the two conjunctive clinical criteria for the determination of death that are stipulated in the code of practice: irreversible loss of capacity for consciousness and somatic integration of bodily biological functions. We argue that: the tests of brainstem function were not properly undertaken in this case; the two conjunctive clinical criteria set forth in the code of practice cannot be reliably confirmed by these tests in any event; and absent authentication of the clinical criteria of death, the code of practice wrongly invokes a secular definition of death based on the loss of personhood. Consequently, the moral obligation of a pluralistic society to honor and respect diverse religious convictions to the greatest extent possible is being violated. Re A is contrasted with the US case of Jahi McMath in which the court accommodated parental religious objection to the determination of neurological death codified in the Uniform Determination of Death Act. We conclude that the legal system in the United Kingdom should not favour a secular definition of death over a definition of death that is respectful of religious values about the inviolability and sanctity of life. We recommend the legal recognition of religious accommodation in death determination to facilitate cultural sensitivity and compassionate care to patients and families in a pluralistic society. (shrink)