This chapter contains sections titled: The Clinical Encounter Medical Paternalism Re‐examined Ethical Frameworks The Temptation to Deceive Different Forms of Deception Communicating Outside Medicine Character, Context, and Care References Further reading.

ABSTRACT This paper reviews the dynamics behind, and ethical issues associated with, the phenomenon of drug resistance. Drug resistance is an important ethical issue partly because of the severe consequences likely to result from the increase in drug resistant pathogens if more is not done to control them. Drug resistance is also an ethical issue because, rather than being a mere quirk of nature, the problem is largely a product of drug distribution. Drug resistance results from the over‐consumption of (...) antibiotics by the wealthy; and it, ironically, results from the under‐consumption of antibiotics, usually by the poor or otherwise marginalized. In both kinds of cases the phenomenon of drug resistance illustrates why health (care) – at least in the context of infectious disease – should be treated as a (global) public good. The point is that drug resistance involves ‘externalities’ affecting third parties. When one patient develops a resistant strain of disease because of her over‐ or under‐consumption of medication, this more dangerous malady poses increased risk to others. The propriety of free‐market distribution of goods subject to externalities is famously dubious – given that the ‘efficiency’ rationale behind markets assumes an absence of externalities. Market failure in the context of drug resistance is partly revealed by the fact that no new classes of antibiotics have been developed since 1970. I conclude by arguing that the case of drug resistance reveals additional reasons – to those traditionally appealed to by bioethicists – for treating health care as something special when making policy decisions about its distribution. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Kennedy Institute of Ethics Journal 10.2 (2000) 171-174 [Access article in PDF] Bioethics Inside the Beltway The Oversight of Human Gene Transfer Research LeRoy Walters Jesse Gelsinger's death last September in a gene transfer study being conducted at the University of Pennsylvania has helped to spark a national debate. In part, this debate parallels the broader discussion of how human subjects research should be reviewed and regulated (...) in the United States. However, human gene transfer research is one of a handful of biomedical technologies that seem to deserve special attention, at least in the early years of their development.The major participants in the national debate on human gene transfer include the National Institutes of Health (NIH), the Food and Drug Administration (FDA), the National Bioethics Advisory Commission, members of Congress, biotechnology and pharmaceutical companies, disease-oriented advocacy groups, reporters, and academics. At the December 1999 meeting of the NIH Recombinant DNA Advisory Committee (RAC), the protocol that involved Jesse Gelsinger was a central focus of discussion, but other topics emerged as well. One ad hoc panel reviewed adverse events that had occurred in other research protocols using adenovirus vectors, while a second proposed changes in the general system for reporting adverse events to NIH and the RAC.During the first several months of the year 2000, the United States Congress also became involved in the human gene transfer debate. In February, Senator Bill Frist (R-TN) convened a hearing to which Jesse Gelsinger's father, representatives of NIH and FDA, and several other witnesses were invited. At approximately the same time, the House Commerce Committee and its Subcommittee on Oversight and Investigations initiated their own inquiries, asking the Office of Inspector General at the Department of Health and Human Services to review the oversight roles of NIH and FDA. In March and April, the House committee also wrote directly to the NIH Director, the FDA Commissioner, and the President of the University of Pennsylvania, requesting extensive documentation on gene transfer, in general, and the trial in which Jesse Gelsinger was involved, in particular. Congressman Henry Waxman (D-CA) and Senator Edward Kennedy (D-MA) have also raised questions and proposed solutions in multiple letters to the NIH Director and the Secretary of Health and Human Services. [End Page 171]The major general questions that have emerged from this discussion are the following:(1) What kinds of information about adverse events should be reported by researchers or sponsors during the course of human gene transfer trials?(2) To what group or groups should adverse-event information be reported? How often and in what ways should the information be analyzed?(3) Should the information about adverse events remain confidential, or should it be discussed publicly?(4) How can the disclosure and consent process in gene transfer trials be improved?(5) Which federal agency should have primary responsibility for overseeing human gene transfer research, and how can it best fulfill its oversight role?How these questions are answered will have immediate relevance to the field of human gene transfer research as it enters into its next phase. At the same time, the models that are created for this important cutting-edge field also may be useful in other complex or controversial arenas of biomedical research, for example, xenotransplantation or human embryonic stem-cell research. In addition, the lessons learned from this one important area of human subjects research may suggest ways to improve protections for all the volunteers who make clinical research--and medical progress--possible.In the remainder of this article, I will turn from reporting, in as objective a way as possible, on the status of the public policy debate about human gene transfer research to suggesting measures for improving the current oversight system for such research. My initial general recommendation is that we should not expect a single regulatory agency to be solely responsible for a field as large and dynamic as human gene transfer research. Rather, there should be some helpful redundancy or, to change the metaphor, checks and balances in the public oversight of this field. Thus, an... (shrink)

Our society has long sanctioned, at least tacitly, a degree of conflict of interest in medical practice and clinical research as an unavoidable consequence of the different interests of the physician or clinical investigator, the patient or clinical research subject, third party payers or research sponsors, the government, and society as a whole, to name a few. In the past, resolution of these conflicts has been left to the conscience of the individual physician or clinical investigator and to (...) professional organizations. The public is no longer willing to allow health care providers to wholly govern their own conflicts of interest for several reasons. These include: new forms of health care financing and delivery that provide innovative and lucrative opportunities for physician or insurer enrichment at patient expense; the increased importance of commercial research support as peer-reviewed governmental research support has decreased; evidence that physicians and clinical investigators too frequently resolve conflicts of interest in their own favor; and a general societal mistrust of authority. This volume represents a multidisciplinary effort, drawing from philosophy, medicine, law, economics and public policy to identify and categorize conflicts of interest in medical practice and clinical research, and, where possible, to offer a mechanism for resolving them. Part I addresses conflicts of interest from a theoretical perspective, offering basic concepts and analytical frameworks. The second part discusses two topics prominent in current health care policy debates--self-referral and financial incentives to limit care. Part III examines conflicts of interest generated by pharmaceutical industry involvement in clinical practice and research. The final section deals with conflicts of interest in clinical research in several contexts, including institutional reviews boards, clinical trials, Cooperative Research and Development Agreements between government and private researchers, brokerage of research subjects by Contract Research Organizations, and cost-effectiveness studies. (shrink)

Over the past 15 years, medical schools have paid some attention to the importance of developing students' communication skills as part of their medical education. Over the past decade, medical ethics has been added to the curriculum of most U.S. medical schools, at least on paper. More recently, there has been growing discussion of the importance of professionalism in medical education. Yet, the nature and content of these fields and their relationship to (...) one another remains confused and vague, and that lack of clarity, in turn, impairs the effectiveness of medical education. This ambiguity invites serious contention over who should design and teach the curriculum as well as when, where, and how it should be taught. (shrink)

[T]each the law to empower physicians individually and collectively to use the law and law colleagues to serve patients and promote public welfare; in short to better foster the goals of the medical profession.And yet:[A]ntipathy appears to be deeper and more pervasive than ever before, making it hard to imagine that relations between attorneys and physicians can get much worse.It has long been recognized that an understanding of at least some core legal rules and concepts is an (...) class='Hi'>important piece of medical training. To address this, law is now typically part of the core medical school curriculum, often incorporated into bioethics and/or practice of medicine coursework — whether as part of a distinct course or series of courses or threaded through the curriculum. While often this education focuses on rules, some have recommended that it also include fundamentals of legal reasoning, and go beyond knowledge to include skills, attitudes, and behaviors vis-à-vis the law. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Teaching Ethics in the Health Care Setting Part I:Survey of the LiteratureMary Carrington Coutts (bio)The last twenty years have brought important changes to health care and health care education. Educators and students alike face an enormous number of new fields of study and new medical technologies. Health care professionals and institutions are also facing new challenges in the form of shrinking economic resources, and the (...) AIDS epidemic. They must also respond to increased patient participation in health care decisions, and public concern about abortion and euthanasia. These challenges to the health care professional have compelled educators to accommodate ethics within their already overcrowded curriculum. Those same dilemmas have influenced health care institutions to become active in health care ethics education.Medical ethics education gained a foothold in the United States during the late 1960s, when the medical schools of Pennsylvania State University, the University of Florida, and the State University of New York at Stonybrook established programs in the humanities (Pellegrino 1982). In 1978 Robert Veatch noted that formal teaching in medical ethics was rare; most institutions that taught medical ethics used "informal instruction in the apprenticeship mode" (Veatch 1978). However, by 1982 a survey by the American Medical Association (AMA) revealed that all but one of the 127 medical schools had courses that included medical ethics. Thirty eight of these had medical ethics as a required course (Pellegrino 1985). And by 1989, 43 of the 127 medical schools had separate courses in medical ethics, while 100 covered medical ethics within required courses. Medical ethics is now an accepted part of medical curriculum, though it is not fully mature, and its future remains somewhat unclear (Miles 1989).The evolution of ethics in the nursing curriculum has essentially mirrored that of the medical curriculum. A 1977 survey of baccalaureate nursing programs revealed that only 7 percent of nursing programs required courses in ethics [End Page 171] (Aroskar 1977). A decade later a second survey of undergraduate programs identified 85 percent of responding nursing schools as teaching nursing ethics either in separate ethics courses or within other required courses (Cassells and Redman 1989).Though the precise future of health care ethics may be unpredictable, there is little thought that the role of ethics will diminish in importance as the 21st century approaches. Ethics is seen as part of a larger plan to develop and enhance the health professional's human values, social conscience, and interpersonal skills. "This broader effort derives from concerns about the personal attributes and humanistic sensitivity of physicians, the recent overly 'scientized' trend in premedical education, the selection of medical students, and the socialization and cynicism engendered by medical education" (Miles 1989, p. 705).While nearly every medical and nursing school in the United States now teaches ethics in one form or another, the degree to which ethics is integrated into the curriculum varies from school to school. Some ethics courses are required elements of the students' education; some institutions require attendance at seminars and ethics grand rounds. Other schools offer an array of elective courses in topics that relate to ethics in medicine and nursing (including medical humanities, medicine and the law, literature and medicine, history of medicine, patient advocacy, and human values in nursing.) "Brown bag" seminars and journal clubs are also common.There is much debate over how health care ethics should be taught. Some argue that medical professionals should be conversant with theories of ethics and principles of biomedical ethics. Others think that a theoretical approach will alienate already over-worked medical or nursing students, and that instruction in ethical theory should be kept to a minimum. Case studies are frequently cited as a way to involve students in medical decision making, forcing them to analyze problems that they can relate to their own experiences.Additional concerns center around who should teach health care ethics. Frequently, physicians and nurses interested in ethics teach courses. Some commentators see this as the most desirable arrangement, asserting that practicing health care professionals best understand the conflicts faced by physicians and nurses-in-training. However, there is a growing pool of professionals who are undergoing training as medical ethicists. These individuals study ethical theory and bioethical... (shrink)

Surgical ethics is a well-recognized field in clinical ethics, distinct from medical ethics. It includes at least a dozen important issues common to surgery that do not exist in internal medicine simply because of the differences in their practices. But until now there has been a tendency to include ethical issues of anesthesiology as a part of surgical ethics. This may mask the importance of ethical issues in anesthesiology, and even help perpetuate (...) an unfortunate view that surgeons are “captain of the ship” in the operating theater (leaving anesthesiologists in a subservient role. We will have a better ethical understanding if we see surgery and anesthesia as two equal partners, ethically as well as in terms of patient care. Informed consent is one such issue, but it is not limited to that. Even on the topic of what type of anesthesia to use, anesthesiologists have often felt subsumed to the surgeon’s preferences. This commentary takes the case study and uses it as a exemplar for this very claim: it is time to give due recognition for a new field in clinical ethics, ethics in anesthesia. (shrink)

Surgical ethics is a well-recognized field in clinical ethics, distinct from medical ethics. It includes at least a dozen important issues common to surgery that do not exist in internal medicine simply because of the differences in their practices. But until now there has been a tendency to include ethical issues of anesthesiology as a part of surgical ethics. This may mask the importance of ethical issues in anesthesiology, and even help perpetuate (...) an unfortunate view that surgeons are “captain of the ship” in the operating theater (leaving anesthesiologists in a subservient role).We will have a better ethical understanding if we see surgery and anesthesia as two equal partners, ethically as well as in terms of patient care. Informed consent is one such issue, but it is not limited to that. Even on the topic of what type of anesthesia to use, anesthesiologists have often felt subsumed to the surgeon’s preferences. This commentary takes the case study and uses it as a exemplar for this very claim: it is time to give due recognition for a new field in clinical ethics, ethics in anesthesia. (shrink)

Photo ID 222412412 © US Navy Medicine | Dreamstime.com ABSTRACT In a non-military setting, the answer is clear: it would be unethical to treat someone based on non-medical considerations such as nationality. We argue that Battlefield Triage is a moral tragedy, meaning that it is a situation in which there is no morally blameless decision and that the demands of justice cannot be satisfied. INTRODUCTION Medical resources in an austere environment without quick recourse for resupply or casualty evacuation (...) are often limited. The shortage extends not only to supplies like blood products and drugs, but physicians and other medical personnel. In the midst of a mass casualty scenario, such as a battle that includes intense ground fighting, the medical staff will stretch scarce resources and triage casualties according to specific criteria. Typically, they proceed by providing care for the most severely wounded first, referred to here as conventional triage. At times, though, the staff may reverse the triage so that soldiers with minor wounds can return to the fight. In a mass casualty situation, when medical personnel apply conventional triage and treat casualties from opposing forces, a dilemma may arise. We argue that it can be permissible for military physicians to prioritize their own soldiers over enemy combatants in a mass casualty triage, where reverse triage does not apply. The case we will focus on is as follows: Battlefield Triage: During combat operations on a remote island in the Pacific Ocean, a compatriot soldier and an enemy combatant arrive at the compatriot soldier country’s medical treatment facility. Both have similar gunshot wounds to the abdomen, and they arrive with similar conditions. Both have low oxygen saturation and excessive blood loss. The sole physician only has enough time to stabilize one person. The scenario is brief, and we are aware that medical rules of eligibility will most often dictate how the physician proceeds,[1] but this scenario is useful in setting up the question we focus on in this paper: would it be wrong to favor the stabilization of a soldier just because the soldier is the physician’s compatriot? In other words, can nationality serve as an ethically justified tiebreaker in a situation such as Battlefield Triage?[2] In a non-military setting, the answer is clear: it would be unethical to treat someone based on non-medical considerations such as nationality. The AMA’s Code of Medical Ethics asserts that physicians have “ethical obligations to place patients’ welfare above their self-interest and above obligations to other groups.”[3] The World Medical Association’s Declaration of Tokyo affirms that “no motive, whether personal, collective or political, shall prevail against this higher purpose” of alleviating distress.[4] Physicians are taught early on that triage decisions must be medically indicated and made without consideration of factors such as race, ethnicity, religion, social status, and nationality. They are taught that public trust and obligations of justice grounded in equality demand that only medical indications be considered. But military physicians in a military setting are beholden to obligations, duties, and responsibilities as members of the military, and when these obligations, duties, and responsibilities conflict, as they do in Battlefield Triage, which loyalties win out and why?[5] Critics of partiality on national grounds argue that partiality undermines public trust in medicine and justice because everyone should be treated equally regardless of nationality.[6] Proponents of partiality argue that military obligations supersede equality and that justice requires partiality in such cases.[7] Despite the critics’ disagreement, both agree that there is a morally right, perhaps even blameless, course of action. Drawing on insights from virtue ethics, we argue that Battlefield Triage is a moral tragedy in which justice is unattainable and there is no action without moral cost. The assumption that there is a morally right choice is flawed. We argue that while no decision in this scenario is free from moral blame, there are reasons to favor treating one’s soldiers over enemy combatants. I. The Case Against Partiality There is a common assumption that there is a morally right or just decision in Battlefield Triage. A number of organizations and scholars claim that it is wrong for military physicians to favor their own soldiers on the grounds of nationality or some form of ‘group membership.’ (In a conflict involving service members from multiple nations working as a coalition, a soldier from an allied country may receive the same priority as the US service member due to ‘group membership.’) The World Medical Association’s WMA Declaration of Lisbon on the Rights of the Patient, which was reaffirmed in 2015, posits that, “[i]n circumstances where a choice must be made between potential patients for a particular treatment that is in limited supply, all such patients are entitled to a fair selection procedure for that treatment. That choice must be based on medical criteria and made without discrimination.”[8] This echoes what was set forth in Article 12 of the Geneva Conventions, which states that “[o]nly urgent medical reasons will authorize priority in the order of treatment to be administered.”[9] The argument for impartiality in Battlefield Triage is that every person is morally equal, and equality entails that medical distribution is, “based on a combination of medical need and urgency.”[10] This is in keeping with the bioethical principles that are generally applied.[11] II. The Case for Partiality On the other side, there are arguments that favoritism is the ethically right decision in Battlefield Triage.[12] The argument asserts that members of the military form a morally significant community of friends and participation in these relationships demands partiality. Just as parents have strong ethical duties to their children and not just any children, military personnel have ethical duties to their group, a group that involves an affirmation of mutual aid and support. Some have termed these ‘associative duties. According to Michael Gross, obligations of friendship, care, and solidarity “leave very little room for generally applicable principles of justice that would obligate a medic to treat enemy or non-compatriot wounded ahead of their compatriots.”[13] This is true in Battlefield Triage, but it may also be true even if the enemy’s soldier were more seriously wounded: “the ethics of small group cohesion, largely an ethics of care, mostly replaces the demands of impartial justice.”[14] In a more recent article, Gross explains that preferential treatment is ethically justified based on fighting capability and “the special obligations people owe friends, family, and, no less, comrades-in-arms.”[15] To not show partiality to the US soldier would be morally wrong on the grounds of friendship and mutual care.[16] III. The Moral Tragedy of Battlefield Triage Defenders and critics of Battlefield Triage favoritism based on nationality both frame their position as just or fair. For example, Justin List argues that physicians are “bound to practice medical neutrality,”[17] Marcus Adams denies that physicians “possess special ethical obligations” to enemy combatants because of their profession.[18] These perspectives assume that there is a morally right decision and that justice is attainable. The assumption that there is or can be a morally right Battlefield Triage decision, and we need to put our heads together to figure it out, remains strongly entrenched. However, the facts of the situation should give us pause; there are too many people and too few resources, and this demands a decision-making process that determines who will receive scarce resources. By its very nature, a battlefield triage decision has to be made based on some characteristic or value, a characteristic or value that will inevitably favor some at the expense of others. This is precisely why competing analyses “in the military context struggle to resolve these conflicts satisfactorily.”[19] Drawing on the insights of virtue ethics, we suggest that Battlefield Triage is a moral tragedy. Virtue ethics suggests that morality is about acting virtuously, which is to say that we should do what a virtuous person would do in the situation. Ethics is about figuring out how a just, wise, compassionate, loving, and fair person would act, and then doing that, as one grows in virtue. But life is not always clear cut, and it is possible that virtuous people may find themselves in a moral tragedy, a situation in which, through no fault of one’s own, a person must make a morally objectionable decision. After the action the virtuous person “emerges having done a terrible thing, the very sort of thing that the callous, dishonest, unjust, or in general vicious agent would characteristically do.”[20] Stated differently, a moral tragedy presents a virtuous person with two or more courses of action, all of which have a moral cost.[21] In Battlefield Triage, no matter how the physician goes about deciding, there is going to be defensible concern from those not saved. The fact that there are more people than can be helped fosters competing values in battlefield triage: maximize lives saved, treat people equally, treat the worse off, and support the war effort. Treating people equally may create tension between treating the worse off, maximizing lives saved, and supporting the war effort. Reverse triage is a case in point, as supporting the war effort conflicts with treating the worse off first, as is a fair lottery system since deploying a lottery may not maximize lives saved or support the war effort. There can be reasons why one person is selected over another, to be sure. Yet, there are reasons for making a decision, and that the decision is subject to legitimate moral concern is another. To recognize the moral tragedy of Battlefield Triage is to recognize the impossibility of acting blamelessly in the situation. In this situation, the virtuous military physician is going to have to sacrifice important values such as justice, compassion, and respect for others, even with a defensible criterion in hand. The physician will grieve this sacrifice accordingly. The physician may find her decision difficult or stressful, and rightly so, because of what her circumstances require of her. This kind of moral tragedy results “in actions which betray and violate the rights of persons to whom there may be a strong duty of care. When this happens, it properly triggers an appropriate moral emotion since our moral integrity has been violated and this affects how we think of ourselves and what we have become.”[22] Rather than view her triage decision as the morally superior choice, the virtuous military physician will view her decisions in these circumstances in a different light: it is the least bad option in a terrible situation, and she did something ethically problematic, something that is contrary to her moral character. She deeply regrets the circumstances in which she had to act. IV. Virtue Ethics A virtue ethicist has insight into how one should go about deciding what to do in a moral tragedy, although virtue ethics may not be as helpful as one may hope. The goal of the virtuous military physician in Battlefield Triage is to adopt the best course of action or the action that she feels she ought to do, all things considered. This does not make her choice devoid of serious wrongdoing—a decision must be made, but that does not make it just. The virtuous military physician will approach the situation with courage, responsibility, and insight. She will think about the decision carefully, wisely, and conscientiously; she will weigh the goods and harms of the choices before her, in conjunction with a proper conception of the good life, human worth, and understanding of her obligations to others—including chain of command, fellow soldiers, and the medical community. She is attuned to the value of human life and has a reasonable idea of the various ways her decisions will affect others. She recognizes that she is in this non-ideal situation through no fault of her own: she is not the one fighting in battles; she is serving her country as a physician, whose job it is to save lives, treat everyone justly, and promote military objectives. She regrets the decision she is forced to make in battlefield triage, acting “with immense regret and pain,” Hursthouse explains, “instead of indifferently or gladly.”[23] This is because, no matter what decision is made, the virtuous military physician “does something terrible or horrible,” something she otherwise would not do and is contrary to her values.[24] V. A Resolvable Moral Tragedy Instead of asking whether there is a morally right decision, in which a decision is morally blameless and above reproach, the virtue ethicist asks whether there is a decision with a convincing rationale, knowing that a decision can have a clear rationale but still be morally tragic. It is perfectly reasonable to think that different virtuous persons will arrive at different courses of action: “two virtuous agents, in the same situation,” Hursthouse writes, “may act differently” in irresolvable moral tragedies, in cases in which there is no clear course of action.[25] Because a person must act in a moral tragedy, one goal is to identify reasons for choosing the chosen action. Some decisions are clearly indefensible—treating neither the compatriot soldier nor the enemy combatant in Battlefield Triage would be wrong—and some decisions are more problematic than others. If the military physician selects to treat the soldier because she does not like the enemy combatant’s skin color, such a reason would be deeply problematic. But much of the debate over how to act in a moral tragedy is not over clearly indefensible or problematic criteria. Instead, the literature is largely about different standards or implementations of justice. Some scholars defend nation-impartial triage as right, while others defend nation-aware triage as right, and each argues that the other side is promoting an unjust or otherwise wrong solution to Battlefield Triage. We suggest that Battlefield Triage is a resolvable moral tragedy and that virtue ethics offers convincing reasons to prefer the treatment of the compatriot soldier rather than the enemy combatant on the grounds of national identity. Virtues are integral to living a good life, a flourishing life, but as Aristotle observed long ago, human beings are inherently social, interdependent and interconnected in profound ways.[26] This goes beyond the obvious fact that we need each other to survive day to day (one person makes clothes, another farms, and another makes tools); the claim is that a good or flourishing life depends in large part on one’s social network or community. This is why many of Aristotle’s moral virtues are other facing: justice, friendship, generosity, and magnanimity, to name a few. Courage, a typically self-facing virtue, is understood by Aristotle to be the virtue that regards one’s fear of death in battle, a battle fought on behalf of one’s city.[27] All of this remains true today. Namely, there is an important sense in which our community matters to our lives: it is easier to live a good, flourishing life if one is part of a good, flourishing community. Our community is made up of smaller groups, and it is more accurate to say that we are simultaneous members of different groups within a broader community. A person may be part of a family, friend group, research team, large state university, city, state, and nation. Groups can function well or not, as we all have experienced, and this suggests that there are virtues or excellences that groups can instantiate. Good groups are unified in purpose, with each member doing their duty alongside others for the attainment of that purpose. Good groups manifest solidarity among their members. Although Aristotle does not list solidarity as a virtue, a number of modern-day virtue ethicists have begun examining how group solidarity can be a virtue that contributes to a good or flourishing life.[28] Solidarity is not conceptualized as an individual virtue, a virtue possessed by a person in isolation of others; instead, it is a collective virtue, a virtue that is shared among members of a defined group with particular ends.[29] “A group has solidarity to the extent that its members are disposed to: (1) share values, aims, or goals; (2) care about those values, aims, or goals; (3) act in accordance with those values, aims, or goals; (4) trust the testimony of other group members with respect to those values, aims, and goals; and (5) feel a sense of belonging to the group.”[30] The virtue of collective or group solidarity involves individuals having special concern for each other, shared aims and values, trust, loyalty, and a sense of belonging with these specific others. There is a oneness to the group in the pursuit of a definite goal or purpose, involving mutual support and affirmation of each member. As such, the group has ends and goods above and beyond the good of each individual person. Sometimes solidarity requires personal sacrifice for the collective (for example, a father sacrificing food so his child can eat). The virtue of collective or group solidarity is important to the military and medical community at every level, and for clear reasons. In the military, there is a clear hierarchy of command, unity of purpose and end, mutual trust and support in complex settings, and so on. Soldiers need to know they can count on one another, and solidarity grounds a soldier’s ability to trust others and be assured of mutual aid. In medicine, solidarity maintains self-regulation of the profession, shared values and goals, as well as public support, not to mention that day-to-day operations require physician trust, engagement, and effort toward the ends of clinical care. Physicians need to work together, along with others, in pursuit of health, and disunity is sowed when there is mistrust, selfishness, or disengagement among the healthcare team and organization. Importantly, just as we are all members of various groups and hence may manifest group solidarity in different settings, the virtuous military physician instantiates collective solidarity with both the medical profession and the military. Her dual loyalty contributes to the moral difficulty of acting in Battlefield Triage. The military physician has competing obligations to distinct groups and cannot satisfy all obligations in Battlefield Triage. Solidarity with the military supports the consideration of favoring the soldier for reasons of national identity, whereas solidarity with the medical community does not. Something has to give, which is why it is a moral tragedy. The virtuous military physician, therefore, must weigh the costs of each course of action. To fulfill her obligations to the medical community would require that she does not use nationality and other non-medical considerations in Battlefield Triage. Since the soldier and enemy combatant are equally injured, justice would demand a random process, perhaps a flip of the coin. Although this may satisfy obligations the military physician has to the medical community, this would be costly to the physician’s military group. If word gets out that the physician decides who to treat based on a coin toss, soldiers, families, and citizens may become frustrated and angry. Soldier morale may go down if it becomes known that a coin flip led to the preventable death of a soldier and the saving of an enemy combatant who had killed (or attempted to kill) other soldiers. As Gross highlights, military solidarity involves a mutual aid promise that military personnel promise to help one another.[31] A military physician is part of the military and, as such, is part of the mutual aid promise, which would appear to be violated if the physician flips a coin. Treating a member of one’s own team may be psychologically more beneficial than treating an enemy combatant and may lead to less moral distress.[32] Finally, treating soldiers rather than enemy combatants promotes broader military and social aims, including returning soldiers to health, maintaining unity of purpose, and minimizing community suffering from a soldier’s death. Favoring members of one’s group, that is, triage based on nationality in Battlefield Triage, would fulfill obligations of military group loyalty, which is contrary to the values and duties of medicine. It does not seem as though showing favoritism in this particular situation is very costly to the medical community or general public, but this is because there is recognition that the physician is in the military. Medicine is impartial to non-medical indications partly because of fairness and to promote public trust in medicine. However, Battlefield Triage is unique, as medicine is being practiced in a non-public, wartime setting. In ordinary circumstances, a patient’s identity is irrelevant, and physicians ought not play favorites. Since Battlefield Triage is not an ordinary circumstance, decisions based on patient identity may not undermine public trust in medicine. In addition, it is contestable that fairness in Battlefield Triage requires that no consideration be paid to one’s nationality. Fairness is about giving each person their due, what is owed to them, and the case can be made that soldiers who place themselves in danger for the sake of the common good or a just cause are owed special attention when they suffer harm in the line of duty. In other words, soldiers voluntarily undergo risk to themselves for the greater good, and society owes them for this sacrifice. This plausibly includes preferential treatment in a situation such as Battlefield Triage. So, while the medical community affirms justice demands non-preferential treatment, the military community can affirm the opposite. The demands of fairness are unclear at best or in conflict in this situation: demands of physician justice decry favoritism, while demands of military justice support favoritism. Triage not based on nationality is arguably unfair and triage based on nationality may not undermine public trust, after all. All things considered, there is a clear rationale for favoring nationality-based preferential treatment in Battlefield Triage. Adopting a nationality-based preference in this situation is more defensible than not. This does not make such a decision ethically right or just. Preference based on nationality is the least bad decision, but it is not morally blameless. It involves one in a serious moral wrong, a wrong otherwise avoided and contrary to one’s character. The virtuous military physician is in a situation in which obligations conflict, and we disagree with Gross, who posits that care of fellow soldiers “is important to the near exclusion of all else.”[33] Gross fails to appreciate the collective virtue of solidarity as applied to those in medicine. The military physician has duties to fellow soldiers but also to fellow physicians, to the medical community, and humanity. To favor a soldier on grounds of nationality violates her duties and responsibilities to this latter group. She is involved in a moral tragedy and can only seek the most just action given the circumstances, yet, at least in virtue ethics, the action remains far from blameless. CONCLUSION We argue that Battlefield Triage is a moral tragedy, meaning that it is a situation in which there is no morally blameless decision and that the demands of justice cannot be satisfied. As such, the virtuous military physician incurs a moral cost to acting as she does—there is a moral residue. However, despite being a moral tragedy, there are clear reasons to act in favor of treating one’s own, considering group solidarity. As such, these kinds of tragedies are resolvable: virtuous military physicians should favor treatment of their own, although they would do so with sorrow. - [1] Militaries set forth medical rules of eligibility or guidelines used to determine whether a person qualifies for specific medical interventions or treatments in certain circumstances, and these guidelines are binding for a military physician. For example, despite opposition from medical organizations, militaries have adopted reverse triage guidelines for military physicians to follow. For ethical discussion, see Falzone, Elisabeth, P. Pasquier, C. Hoffmann, O. Barbier, M. Boutonnet, A. Salvadori, A. Jarrassier, J. Renner, B. Malgras, and S. Mérat. "Triage in military settings." Anaesthesia Critical Care & Pain Medicine 36, no. 1 (2017): 43-51. https://doi.org/10.1016/j.accpm.2016.05.004 [2] There are issues that are related to this, including the triage of civilians and allied soldiers. We set related issues aside for purposes of this paper [3] American Medical Association, Code of Medical Ethics: Current Opinions with Annotations, 2004–2005 ed. (Chicago, IL: AMA, 2004), 300. [4] American Medical Association, Code of Medical Ethics: Current Opinions with Annotations, 2004–2005 ed. (Chicago, IL: AMA, 2004), 300. [5] This is termed the “dual loyalty” dilemma in military medicine and has been described at length elsewhere: Institute of Medicine (US) Board on Health Sciences Policy. Military Medical Ethics: Issues regarding Dual Loyalties: Workshop Summary. Washington (DC): National Academies Press (US); 2008. Toward a Framework for Resolving Dual Loyalties. Available from: https://www.ncbi.nlm.nih.gov/books/NBK214853/ [6] See Kenneth G. Swan and K.G. Swan, Jr., “Triage: The Past Revisited,” Military Medicine 161:8 (1996): 448–452. https://doi.org/10.1093/milmed/161.8.448; Jerome A. Singh, “American Physicians and dual loyalty obligations in the ‘war on terror,’” BMC Medical Ethics 4.4 (2003): 1–10. https://doi.org/10.1186/1472-6939-4-4; Beam, Thomas E. "Medical Ethics on the Battlefield." Military Medical Ethics: Sect. IV. Medical ethics in the military. Medical ethics on the battlefield: the crucible of military medical ethics 2 (2003): 369-402; Hereth, Blake. "Health justice for unjust combatants." Journal of Military Ethics 20, no. 1 (2021): 67-81. https://doi.org/10.1080/15027570.2021.1949782. [7] See Adams, Marcus P. "Triage priorities and military physicians." In Physicians at war: The dual-loyalties challenge, pp. 215-236. Dordrecht: Springer Netherlands, 2008. Gross, Michael L. "Comradery, community, and care in military medical ethics." Theoretical medicine and bioethics 32 (2011): 337-350. https://doi.org/10.1007/s11017-011-9189-6. Gross, Michael L. "The limits of impartial medical treatment during armed conflict." In Military medical ethics for the 21st century, pp. 71-84. Routledge, 2016. [8] World Medical Association, WMA Declaration of Lisbon on the Rights of the Patient. 5 December 2022, https://www.wma.net/policies-post/wma-declaration-of-lisbon-on-the-rights-of-the-patient/ [9] Geneva Convention for the Amelioration of the Condition of Wounded, Sick in Armed Forces in the Field. 12 August 1949. https://www.un.org/en/genocideprevention/documents/atrocity-crimes/Doc.30_GC-I-EN.pdf. [10] List, Justin M. "Medical neutrality and political activism: physicians' roles in conflict situations." In Physicians at war: The dual-loyalties challenge, pp. 237-253. Dordrecht: Springer Netherlands, 2008. 240 [11] Beauchamp, T., and J. Childress. 2013. Principles of Biomedical Ethics, 7th ed. Oxford, United Kingdom: Oxford University Press. [12] Adams, Marcus P. "Triage priorities and military physicians." In Physicians at war: The dual-loyalties challenge, pp. 215-236. Dordrecht: Springer Netherlands, 2008. [13] Gross, "Comradery, community, and care in military medical ethics," 347. [14] Gross, “Comradery, community, and care in military medical ethics,” 349. [15] Gross, Michael L. "When medical ethics and military ethics collide." Narrative inquiry in bioethics 13, no. 3 (2023): 199-204. 202 https://dx.doi.org/10.1353/nib.2023.a924191 [16] Our argument draws on virtue ethics, from which care ethics derives, and it is worth clarifying how our argument relates to Gross’s. We do not think that the virtue of friendship grounds triage decisions, for we think it is unlikely that the physician and wounded soldier are friends. Instead, as explained below, we think the collective virtue of group solidarity better captures the moral significance of group loyalty and that Gross would agree with us. But since military physicians are part of distinct groups, with competing obligations, the military physician will be forced to sacrifice a value in battlefield triage cases. In other words, we think Gross downplays the dual group membership of a military physician. [17] List,”Medical neutrality and political activism,” 250. [18] Adams,”Triage priorities and military physicians,” 235. [19] London, Leslie, Leonard S. Rubenstein, Laurel Baldwin-Ragaven, and Adriaan Van Es. "Dual loyalty among military health professionals: human rights and ethics in times of armed conflict." Cambridge Quarterly of Healthcare Ethics 15, no. 4 (2006): 381-391. 383. [20] Hursthouse, R. On Virtue Ethics. OUP 1999. 74 [21] Nussbaum, Martha C. "The costs of tragedy: Some moral limits of cost-benefit analysis." The Journal of Legal Studies 29, no. S2 (2000): 1005-1036, 1007. [22] De Wijze, S. (2005). Tragic-remorse–the anguish of dirty hands. Ethical theory and moral practice, 7(5), 453-471, 457. https://doi.org/10.1007/s10677-005-6836-x [23] Hursthouse, 73 [24] Hursthouse, 81 [25] Hursthouse, 72 [26] Aristotle, Politics 1253a8. Reeve, C. D. C., Indianapolis: Hackett Publishing Co., 2017 [27] Aristotle, Nicomachean Ethics. III.6.114a, 34-35. 2002, Nicomachean Ethics, Christopher Rowe (trans.), Oxford: Oxford University Press [28] Byerly, T. Ryan, and Meghan Byerly. "Collective virtue." The Journal of Value Inquiry 50, no. 1 (2016): 33-50. https://doi.org/10.1007/s10790-015-9484-y; Federico, Veronica. "Conclusion: solidarity as a public virtue." Solidarity as a Public Virtue (2018): 495-542. https://doi.org/10.5771/9783845290058. Rehg, William. "Solidarity and the common good: An analytic framework." Journal of Social Philosophy 38, no. 1 (2007): 7-21. https://doi.org/10.1111/j.1467-9833.2007.00363.x [29] Byerly and Byerly. "Collective virtue." 43 [30] Battaly, Heather. "Solidarity: Virtue or vice?." In Social virtue epistemology, pp. 303-324. Routledge, 2022. 304 [31] Ibid., 2011: 341 [32] It might be thought that displaying altruism by helping an enemy combatant at the expense of one’s fellow soldier may be psychologically satisfiying. For evidence that military physicians find it difficult to treat enemy combatants, see Lundberg, Kristina, Sofia Kjellström, Anders Jonsson, and Lars Sandman. "Experiences of Swedish military medical personnel in combat zones: adapting to competing loyalties." Military medicine 179, no. 8 (2014): 821-826. https://doi.org/10.7205/MILMED-D-14-00038. Lamblin, Antoine, Clément Derkenne, Marion Trousselard, and Marie-Ange Einaudi. "Ethical challenges faced by French military doctors deployed in the Sahel (Operation Barkhane): a qualitative study." BMC Medical Ethics 22 (2021): 1-13. https://doi.org/10.1186/s12910-021-00723-2 [33] Ibid., 2011: 344. (shrink)

What I suggest we can see in this brief overview of the literature is an extensive interpenetration on both sides of these debates between scientific, political, and social values. Important shifts in political and social values were of course occurring over the same period, some of them in parallel with, and perhaps even contributing to, these transitions I have been speaking of in evolutionary discourse. The developments that I think of as at least suggestive of possible parallels include (...) the progressive encroachment of public values into the private domain of post-World War II American life, the cold war, the rise of consumerism, and the flowering of what Christopher Lasch calls a “narcissistic individualism.”35 In popular language, the 1960s gave birth to the “me” generation. Perhaps the most tantalizing analogue is suggested by Barbara Ehrenreich's argument for the emergence of a new meaning of masculinity — an ideal of masculinity measured not by commitment, responsibility, or success as family provider, but precisely by the strength of a man's autonomy in the private sphere, his resistance to the demands of a hampering female.36 It is tempting to speculate about possible connections between changes in scientific discourse and developments in the social and political spheres, but such connections, however suggestive, would clearly have to be demonstrated.For now, however, I want to focus on another kind of change —a transformation not so much in the social or political sphere as in the scientific sphere. I make this turn, or return, in support of a more complex account of scientific change that incorporates reverberations within the scientific communty along with social and political changes.In the 1960s, all of biology was undergoing a major transformation in direct response to the dramatic successes of molecular biology. These successes seemed to completely vindicate the values on which the molecular revolution was premised — namely, simplicity and mechanism. Following the victory of Watson and Crick, and of others after them, the fever of that endeavor swept through biology leaving in its wake a new standard of science, and of scientific discourse — one predicated on clarity, simplicity, and analyzability; on the definition of legitimate questions as those capable of clear and unambiguous answers. Every biological discipline felt it — even evolutionary biology, which in some respects was at the furthest pole. Perhaps precisely because it seemed conceptually so remote, evolutionary biology may have felt it most of all. Lewontin inadvertently provides us with some direct support for this view. Indeed, he begins his introduction to Population Biology and Evolution with the following remarks: The twenty years since World War II have seen a vindication in biology of our faith in the Cartesian method as a way of doing science. Some of the most fundamental and interesting problems of biology have been solved or are very nearly solved by an analytic technique that is now loosely called “molecular biology.” But it is not specifically the “molecular” aspect of biology of the last twenty years that has led to its success. It is, rather, the analytic aspect, the belief that by breaking systems down into their component parts, by simplifying them or using simpler organisms, one can learn about more complex systems. As it happens, the problems that were attacked and are being attacked by this method lead to answers in terms of molecules and cell organelles.... There is a host of problems in biology, however, that has been much neglected in these twenty exciting years, because the answers to them cannot be meaningfully framed in molecular and cellular terms.37Lewontin is referring, of course, to problems in evolution. The remainder of his remarks is devoted to an argument for the applicability of the method, if not the content, of molecular biology to these problems. He writes, “It is not the case that molecular biology is Cartesian and analytic while population biology is holistic. Population biology is properly analytic and operates, within the framework of its own problems, by the process of simplification, analysis, and resynthesis.”38 With these remarks, he leads into the criticism of the “holists” who have “held up progress.”This new ethic of simplicity, clarity, and mechanism — embodying the very virtues lauded by Williams — was explicitly carried into evolutionary biology in the name of scientific progress. As it happened, the values implied also fit conveniently well with other values — each set of values providing crucial support for the other.However substantive the scientific gains may have been in some respects, the net effect of this ethic has also been a systematic “perceptual bias” — a bias with profound practical consequences for the entire program of methodological individualism in evolutionary biology, if not elsewhere as well. It may well be that the whole is equivalent to the reconstituted aggregate of its parts, if, in the process of aggregation or summation, all possible interactions among the parts are included. But if certain kinds of interactions are systematically excluded, our confidence in that program necessarily founders. My claim here is that such systematic exclusion does occur, and that it occurs on a number of different levels. To briefly review the interlocking kinds of “bias” that I see occurring in practice, I suggest the following schematic listing:On the most general level: The ethic of simplicity — the privileging of certain values, even certain methodologies, as having an a priori superior claim to scientific credibility.Only slightly less general, and crucially related, is the equation of “scientific” with “tractible”: Given the techniques of analysis available, the equation of science with what we can do inevitably leads to a systematic technical bias favoring simplicity. That is, because we don't know how to model complex dynamics, nonlinear interactions are systematically biased against because of the limitations of our technical know-how. The consequences of this equation of the scientific with the tractible are greatly compounded by the additional equation between what we can do and what is — that is, by our temptation to confuse tractibility with reality.Finally, and also closely related, a further kind of elision occurs even within the confines of tractibility. This kind of elision — taking the form almost of inferring tractibility from one's prior assumptions of what is real — is exemplified by the history of a mathematical ecology of mutualism. Even when mutualism can be introduced into the same technical machinery, it is still not pursued. The basic assumption is that competition is what is real, not because it is easier to model, but because it is what we expect. When the actual difficulties of modeling competition are then in turn suppressed, as in the Robert May story, what we have, given the temptation to equate the tractible with the real, is the possibility of a truly self-fulfilling prophecy. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Teaching Ethics in the Health Care SettingPart II: Sample SyllabusMary Carrington Coutts (bio)The National Reference Center for Bioethics Literature at the Kennedy Institute of Ethics receives many inquiries from instructors at institutions that are just beginning to teach medical ethics. In an effort to assist those individuals, we have devised a syllabus that could be adapted for many uses. This is intended to be an (...) introductory level syllabus, perhaps one that would be appropriate for continuing staff education in a hospital or for an undergraduate college course. Of course, every instructor has his or her own style and preference for course content. This is offered merely as a place to start.Recognizing that participants bring a variety of backgrounds to a course, four possible text books and two casebooks have been selected as texts for a course in health care ethics. There are a number of other books that also could have been chosen. Some of these are listed in Scope Note 15: Basic Resources in Bioethics (published in the Kennedy Institute of Ethics Journal 1 (1): 75-90, March 1991). Other video selections are listed in Scope Note 9: Bioethics Audiovisuals: 1982-Present (1988); (available directly from the National Reference Center for Bioethics Literature). Additional recommendations for works that provide cross-cultural or international views of medical ethics appear in the supplemental readings list at the end of this syllabus.TextbooksBiomedical Ethics. Edited by Thomas A. Mappes and Jane S. Zembaty. 3rd ed. New York: McGraw-Hill, 1990, 641 pp. Cited: (M&Z). This text is well-suited for undergraduate education, with selected readings by philosophers, lawyers, and physicians. Includes 45 brief case studies to [End Page 263] illustrate various units of readings.Contemporary Issues in Bioethics. Edited by Tom L. Beauchamp and LeRoy Walters. 3rd ed. Belmont, CA: Wadsworth Pub. Co., 1989, 655 pp. Cited: (B&W). Appropriate for upper-level undergraduate or graduate education, this text includes selected readings by important philosophers, lawyers, physicians, and organizations. Includes the abridged texts of many significant court cases and government or organizational documents. Does not include case studies.Ethical Issues in Modern Medicine. Compiled by John Arras and Nancy K. Rhoden. 3rd ed. Mountain View, CA: Mayfield, 1989, 585 pp. Cited: (A&R). This text is suitable for upper-level undergraduate or graduate studies. It includes selections from well-respected lawyers, philosophers, and a few physicians. Includes excerpts from important court cases and policy documents. Provides only a few hypothetical case studies but does relate some authentic cases that are relevant to the various sections.Taking Sides: Clashing Views on Controversial Bioethical Issues. Edited by Carol Levine. 3rd ed. Guilford, CT: Dushkin Pub. Group, 1989, 370 pp. Cited: (L). A compilation of contrasting readings from the popular Hastings Center Report, this book is appropriate for undergraduate or continuing health care education. It does not include an introduction to basic biomedical ethical theory. Perhaps less systematic in its approach to bioethics than the previous textbooks, this book covers twenty topics relating to reproduction, death and dying, human and animal experimentation, and selected public policy issues. Provides pro and con arguments for each issue.CasebooksCases in Bioethics: Selections from the Hastings Center Report. Edited by Carol Levine. Rev. and updated ed. New York: St. Martin's Press, 1989, 291 pp. Cited: (HCR). This text includes cases studies taken from the well-known Hastings Center Report. Two or three commentaries usually accompany each case.Pence, Gregory E. Classic Cases in Medical Ethics: Accounts of the Cases That Have Shaped Medical Ethics, With Philosophical, Legal, and Historical Backgrounds. New York: Mc-Graw-Hill, 1990, 398 pp. Cited: (CC). This book describes a collection of famous (and infamous) cases from the history of biomedical ethics. The accounts of the cases here are more detailed than in other texts, and the style is more casual. [End Page 264]Course OutlineBelow are possible topics for discussion, listed with the relevant portions for each book. It is anticipated that only one textbook and one casebook would be chosen for a course. Whenever possible, price information for video purchase or rentals has been included, however this information is subject to change.Session 1... (shrink)

Photo by Hannah Busing on Unsplash INTRODUCTION Religion has long provided guidance that has led to standards reflected in some aspects of medical practices and traditions. The recent bioethical literature addresses numerous new problems posed by advancing medical technology and demonstrates an erosion of standards rooted in religion and long widely accepted as almost axiomatic. In the deep soul-searching that pervades the publications on bioethics, several disturbing and dangerous trends neglect some basic lessons of philosophy, logic, and history. (...) The bioethics discourse on medical aid in dying emphasizes similarity over previously recognized important distinguishing features. For example, it overplays a likeness between assistance in dying and the withdrawal of life-saving technology. In many bioethics’ topics, arguments based on a logical continuum are used to question the lines demarcating important moral differences. l. The Line Between Ethical and Not: Logic Based on Continuum Careful case selection, often either end of a continuum, allows the tearing down or ridiculing of many rules and codes across most professions and fields of interest. This situation holds true for traffic laws as well as medical ethics guidelines. It is relatively simple for those who desire to attack a particular viewpoint by selecting a case that makes that position seem untenable. In the ethics realm, good and bad medicine exist at opposite ends of an ethical continuum, with many practices lying in between. For example, much of medical ethics exists between the Nazi criminal physicians and the most sainted nurse or physician. A gradual progression occurred over less than two decades from a utilitarian position that supported limited euthanasia for those with certain mental illnesses to genocide. German society embraced a utilitarian ethic in which the value of human life no longer was intrinsic but instrumental.[1] Many morally significant points on a continuum were then ignored as the misguided utilitarian policy rampantly continued. A point in the continuum to distinguish between ethically justifiable and that which is not can be difficult to identify compared to the two extremes. This continuum is not unique to ethics but can be applied to almost any other aspect of human life and endeavor. Between a severely ill schizophrenic person and a superbly well-adjusted individual, there is a continuum of mental and psychological function. The existence of a continuum should not paralyze thinking and prevent us from drawing lines and identifying moral differences based on objective criteria as well as moral philosophy. Yet, by focusing on a continuum, many bioethicists use logic to disregard dividing lines between an "ethical" and an "unethical" act. Unfortunately, sometimes bioethicists draw revolutionary conclusions that would change the scope of medical practices which is accepted as ethical. There are many examples of similar shifts on the continuum. Many authors argue for the ethical permissibility of abortion by pointing out that the human fetus is no different in various characteristics, one arguing it is as like an ape or chick as it is like a person,[2] and does not achieve unique human and individual characteristics until well into the first year of life.[3] While human fetuses arguably do not have certain distinctive qualities of personhood, most people shy away from the logical next conclusion: permitting infanticide. For example, Joshua Lederberg condemns infanticide, in the face of biological illogic, because of our emotional commitment to infants, to me, a relatively weak explanation. Sir Francis Crick suggests we might consider birth at two days of life in order to decide whether an infant is a "suitable" member of society.[4] Giublini and Minerva suggest that infanticide should be permissible since late pregnancy abortions are permissible, arguing there is no significant difference between a fetus just before birth and an infant just after birth.[5] Clearly the continuum approach would allow for subjective arguments in favor of later infanticide at other points many days post-birth. Years ago, with a cynical tone, I mentioned infanticide as a further step on the continuum beyond abortion, and I was rightly shouted down as being deliberately provocative to assert the logic would ever stretch so far. While it is not an accepted mainstream position, the movement in academic settings from widespread condemnation to limited possible acceptance of infanticide has taken place in an incredibly short time. Public opinion and medical opinion in these areas have shifted dramatically in a short time. In another area, from a biological and chemical point of view, there is a continuum from man down to a single carbon atom. Yet, it would not seem logical to ignore the emotional differences, the meaning of personhood, or the moral distinction between killing an insect and killing a person. ll. A False Continuum: Medical Aid in Dying I assert that there has been an erosion of ethical guidelines in recent years attributable to using continuums to camouflage important distinctions. James Rachels’ work on active and passive euthanasia, which contends that the two are ethically identical, exemplifies that logic.[6] He illustrates this thesis, using a continuum to compare different scenarios with like consequences as morally equivalent, by comparing the deliberate drowning of a child with a deliberate failure to rescue a drowning child when easily able to do so. The author's comparison proposes that since much of the medical profession has already made peace with withholding treatment in order to hasten death, consistency inexorably demands that we permit active euthanasia as well.[7] When permission for active euthanasia was first introduced, it was limited exclusively to patients suffering severely from an intractable, incurable, and irreversible disease. These guidelines have been continuously eroded. There is now a substantial serious consideration for permitting active euthanasia of healthy elderly individuals who feel that they have completed their lives and are "tired of living."[8] There are many moral and factual differences along the ethical continuum. In human life, there is a difference between a live baby and a fetus, between a viable fetus and one that is not, between a fetus and a zygote, and between a zygote and a sperm cell. Similarly, there is a difference between pulling a trigger to kill someone and not interfering in preventing his death, which is reprehensible though both may be. There is a difference between not resuscitating an 80-year-old man with cancer when his heart stops and injecting him with a fatal dose of potassium chloride. I argue that an overt act of taking life repels civilized human beings is to be commended and encouraged as the reverence for human life or even for just a moment of human life is one of the great contributions of our civilization. CONCLUSION As an orthodox Jew, I feel that divinely inspired guidelines that have stood the test of centuries shape my beliefs, and such guidelines contradict medical aid in dying. I cannot speak to the viewpoint of those who do not access religion in defining their moral stance, nor do I implicate them in the current bioethics' trends, as I am not aware of the personal role of religion in the lives of most such authors. While many nonreligious people have a firm philosophical grounding and oppose medical aid in dying, I suggest that in the absence of any religious or other absolute standards, developing logically defensible ethical guidelines may be challenging. At the least, religion may play a role in defining the points on the continuums that are ethically meaningful and refuting the trending beliefs that if the endpoint is the same, allowing different methods of arriving at that end are somehow ethically equal. The continuum of ways death may result does not negate analysis of whether death is brought about in ways that recognize the importance of life. The German philosopher Hans Jonas said, "It is a question whether without restoring the category of the sacred, the category most thoroughly destroyed by the scientific enlightenment, we can have an ethics able to cope with the extreme powers that we possess today and constantly increase and are compelled to use."[9] While countries vary on the role of religion in policy, with many emphasizing freedoms of religion, a recent position paper released by a group of Jewish, Christian, and Moslem leaders suggested the need for agreement on the unique sanctity of human life.[10] I would recommend that such a document serve as an example of consensus on critical foundational bioethical guidelines for democratic secular societies. - [1] Alexander L Medical science under dictatorship. New England Journal of Medicine, 241, p39-47 DOI10.1056/NEJM194907142410201 [2] Lederberg J. A geneticist looks at contraception and abortion, Annals of Internal Medicine 67, sup 2, 25-27. https:/doi.org/10.7326/0003-4819-67-3-25 [3] Ibid. [4] Editorial, Sociology: Logic of biology. Nature 220, 429 https://www.nature.com/articles/220429b0 [5] Giublini A Minerva F After-birth abortion: why should the baby live. J Med Ethics 39, 261- [6] Rachels J Active and passive euthanasia. New England Journal of Medicine 292, 78-80 [7] Ibid. [8] Cohen-Almagor R Euthanizing people who are "tired of life". in Euthanasia and Assisted Suicide-Lessons from Belgium. Ch 11 of Euthanasia and Assisted Suicide, Cambridge University Press pp173-187. 2017 and DOI; https://doi.org/10.1017/9781108182799.012 [9] Hans Jonas, Technology and Responsibility: Reflections on the New Tasks of Ethics, 1972, found as Chapter IX, Philosophical Essays, 1980. https://inters.org/jonas-technology-responsability [10] A position paper of the Abrahamic Monotheistic religions on matters concerning the end-of-life. Vatican Press 28 October 2019 https://press.vatican.va/content/salastampa/en/bollettino/pubblico/2019/10/28/191028f.html. (shrink)

The World Health Organisation's programme for the eradication of poliomyelitis as currently practised in India raises many ethical issues. In this paper we concentrate on just two. The first is the balance to be struck between the risks and benefits generated by the eradication programme itself. The issue of risks and benefits arises in relation to the choice between two different vaccine types available for polio programmes: oral polio vaccine (OPV) and inactivated polio vaccine (IPV). OPV is the vaccine currently (...) used in the eradication campaign in India. We argue that given the current risks/benefits profile of this vaccine, there is an urgent need to review the programme and take remedial action to address existing problems (at least in India). The second issue we discuss is the fact that there is little effort to gain the informed consent of the parents of vaccinated children, as they are not currently told about the potential limitations of OPV or the possibility of vaccine-induced harm. We suggest that such a policy might be justifiable, given the importance of polio eradication, but only if there is a system of compensation for vaccine-induced harm as part of the eradication programme itself. There is a real danger that if these issues are not addressed then public trust in the eradication programme and vaccination programmes as a whole will be lost. (shrink)

There is a large literature exploring the concept of ‘health promotion’. However, the meaning of the term remains unclear and contested. This is for at least two reasons. First, any definition of ‘health promotion’ is going to have to outline and defend an account of the notoriously controversial concept of ‘health’, and then suggest how (and why) we should promote it. Second, health promotion clearly has some overlap with ‘public health’, but it is far from clear how they are (...) related. Is health promotion part of public health or is health promotion a radically different type of activity from public health? Answering this question requires engaging with tricky professional as well as contentious conceptual issues. Some advocates of health promotion talk as though public health is problematic: seen as medical, physiological in focus and reductionist in approach, whereas health promotion, on this view, is focused on the whole person in a social environment. However, to an outsider this looks more like an attempt to artificially (and rather crudely) define and protect professional boundaries, rather than a contribution to conceptual analysis. There seems no good reason why public health cannot take into account the role of social, political, economic and cultural factors and their impact on health. Indeed, much work in public health does precisely this, and uses a wide range of methodologies drawn from non-medical disciplines such as geography, sociology and psychology, not just epidemiology. It seems much more sensible to see health promotion as being one vitally important aspect of the work of public health, rather than something markedly distinct. We will assume here that this is the case and focus instead on the first issue: what is health promotion? (shrink)

Patient autonomy is one of the four pillars of modern medical ethics. In some cases, however, its value is not absolute and autonomy may be overridden by sufficiently important matters of public interest. Coroner’s autopsies represent an example of when the wishes of the deceased and their family may come in conflict with the benefits of knowledge gained from understanding the cause of death. Current legislation governing coroner’s autopsies relies on the assumption of their obvious public benefit, (...) hence consent for them need not be sought. This interpretation has attracted controversy, as exemplified by the case of Rotsztein vs HM Senior Coroner and a recent study questioning the prevalent use of invasive autopsy. However, this issue has received little recent attention in ethical literature. In this essay, the ethical nature of coroner’s autopsies in cases of natural deaths with unexplained causes is examined as a balance between patient autonomy and the value of knowledge gained from them. This is done by analysing a case which under current legislation warrants coroner’s autopsy, however, its ethical justification remains contentious. This discussion is expanded by discussion of non-invasive alternatives and comparison to another situation which balances individual autonomy with public benefits—organ donation. The conclusion of this analysis is a moral middle ground in which objection to invasive autopsy could be respected once issues of overriding public interest are excluded, or at least non-invasive alternatives should be considered, with coroners left responsible for demonstrating specific public needs that could override objection. (shrink)

From the beginning, a code of ethics for bioethicists has been conceived of as part of a movement to professionalise the field. In advocating for such a code, Baker repeatedly identifies ‘having a code of ethics’ with ‘professionalization’. The American Society of Bioethics and Humanities (ASBH) echoes this view in their code of ethics for healthcare ethics consultants (HCECs)1 and the subsequent publication in the American Journal of Bioethics.2 Taking for granted that a code of (...) ethics could be a valuable asset for HCECs, this essay has two aims. First, there are good reasons to doubt that the label ‘profession’ has significant meaning for HCECs. Attempts to accurately conceive of a profession fall into two broad camps: substantive and formal. Substantive conceptions should be rejected. Specifically, substantive conceptions beg the question about what it means to be a profession, which produces devastating problems for practical application. Formal conceptions of profession (eg, Davis’ conception3) avoid begging the question, but do so at the cost of identifying the responsibilities of a profession. Using the term ‘professional responsibilities’, then, requires additional explication and classifying HCECs as professionals requires the identification of their role-specific responsibilities.i Second, this essay will critique the ASBH code of ethics for HCECs as a first articulation of these responsibilities. As written, this code of ethics has limited value for HCECs because most of the responsibilities identified in this code do not identify HCEC-specific responsibilities. In closing, some important strategies to improve upon this initial attempt to define the responsibilities of HCECs are identified. For at least the last decade, Baker has encouraged bioethicists to adopt a code of ethics. Throughout this effort, Baker intertwines having a code of ethics with becoming a profession: ‘Is it time for bioethics to assert its integrity by developing …. (shrink)

Chinese authors are the third most frequent submitters to the JME. However, as will be apparent from the content published in the journal, relatively fewer papers from China are accepted. That is not due to a lack of important scholarship in China. We recently contributed to a highly successful conference with Professor Xiaomei Zhai at Peking Union Medical College, Beijing and were impressed by the increasing awareness, analysis and progress of medical ethics in China, including in (...) the area of organ transplantation. However, few of these presentations make it into print. It is therefore important to make the criteria that inform editorial judgements as transparent as possible. There are several reasons why the acceptance rates for the JME are higher in some countries than others. Some of them are related to different views about what constitutes medical ethics or research. In some contexts, articles are not recognised as research unless they are empirical and the bulk of papers submitted from some countries have no ethical argument. Philosophical traditions vary across countries and papers that are primarily exegetical, in the sense that they describe what a famous philosopher would say about an issue, usually do not make it into the JME. There are other journals that accommodate different views about what counts as research or ethics, so authors should match their papers to the content that a journal publishes. However, academic journals can be opaque about how authors should pitch their papers so as to maximise their chances of publication. …. (shrink)

In 1997, after long social debates, the Japanese government enacted a law on organ transplantation from brain-dead bodies. Since 1993, on gene therapy, administrative agencies have issued a series of guidelines. This study seeks to elucidate when people became aware of the issues and when they formed their opinions on organ transplant and gene therapy. At the same time, it aims to examine at which point in time experts, those in university ethical committees and in academic societies, consider these technologies (...) became accepted among the public. A self-administered questionnaire was sent by mail to a stratified random sampling of 3000 people nationwide in Japan. Another questionnaire was sent both to the member societies of the Japanese Association of Medical Sciences and to the ethical committees of all the medical schools in Japan. Results of the surveys indicated that many of the public remained undecided on the desirability of organ transplant or gene therapy at the time of enactment of official guidelines. A substantial part of them formed their opinions in subsequent periods, especially around the time of first implementation and thereafter. Experts of the academic societies and of the university ethical committees regarded the time of implementation as an important factor in the acceptance of the technologies in society. Since many people formed their opinion during the period of technological implementation, communications efforts to facilitate public understanding of science and technology, as well as to advance practical discussion on policy alternatives in this period can play a key role in determining the fate of technological innovation and ethical debates in medicine. (shrink)

Background Q-CEP (Qualificação dos Comitês de Ética em Pesquisa que compõem o Sistema CEP/Conep) is a nationwide project resulting from a partnership between the Brazilian National Research Ethics Commission (Conep), the Ministry of Health and Hospital Moinhos de Vento (HMV). It was developed to consolidate policy for ethical review of research with human beings in all members of the CEP/Conep System, Brazil’s national system of institutional review boards. The aim of this study was therefore to report on the experience (...) and results of the Q-CEP project. Methods An observational, retrospective study includes data from the Q-CEP, obtained from visits to all the institutional research ethics committees (RECs) in the country. The actions implemented by Q-CEP were part of a two-step process: (i) training visits to each REC; (ii) development of distance learning modules on strategic topics pertaining to research ethics evaluation. The data presented herein cover step one (training visits), defined by Q-CEP as the diagnostic stage of the project. For a country with social and economics inequalities such as Brazil, this is a particularly important stage; an accurate picture of reality is needed to inform planning of quality improvement strategies. Results In 2019–2021, Q-CEP visited 832 RECs and trained 11,197 people. This sample covered almost all active RECs in the country; only 4 (0.5%) were not evaluated. Of the 94 items evaluated, 62% did not reach the target of at least 80% compliance and around 1/4 (26%) were below 50% compliance. The diagnostic stage of the process revealed inadequacies on the part of the RECs in their ethical reviews. The analysis of informed consent forms showed compliance in only 131 RECs (15.74%). The description of pending issues made by RECs in their reports was compliant in 19.33% (n = 161). Administrative and operational aspects were also considered inadequate by more than half of the RECs. Conclusions Overall, Brazilian RECs showed poor compliance in several aspects of their operation, both in ethics evaluation and in other processes, which justifies additional training. The Q-CEP project is part of a quality improvement policy promoted by the Brazilian Ministry of Health. The data obtained in the diagnostic step of the project have contributed to the qualification and consolidation of one of the world’s largest research ethics evaluation systems. (shrink)

Our aim in this paper is to suggest that most current theories of global justice fail to adequately recognise the importance of global public goods. Broadly speaking, this failing can be attributed at least in part to the complexity of the global context, the individualistic focus of most theories of justice, and the localised nature of the theoretical foundations of most theories of global justice. We argue ? using examples (particularly that of protecting antibiotic efficacy) ? that any (...) truly effective theory of global justice must recognise the importance of global public goods. Global public goods confer significant benefits to individuals yet can only be effectively promoted and preserved through collective action and the restriction of individual choice; something which most theories of justice are structurally unequipped to sufficiently promote. (shrink)

Since its inception, bioethics’ principled stance has been to argue against paternalism and elitism, and for an inclusive ethical perspective. But at least in North America, the growth of bioethics as a special area of applied ethics has created conflicts within the field itself. Those who, a generation earlier, argued against paternalism and for both professional and public accountability in medical decision making are now part of the decision making process. Too often, it is argued in (...) this paper, their allegiance is to the employer, or to a view of medicine that is institutionally based. As a result, it is suggested by this review, medical ethicists have adopted the perspective that, in the early 1970s, they most criticised. The answer, it is argued here, is to revisit a lexicographical ordering of responsibility in bioethics, one that recognises professionals as individuals with responsibilities, as citizens with a public posture, and finally, as professionals involved in the process of medical decision making. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:IntroductionStuart J. Youngner (bio), Laura A. Siminoff (bio), and Renie Schapiro (bio)This issue of the Kennedy Institute of Ethics Journal (KIEJ) centers on a piece of empirical research. The motivation behind the study of Laura Siminoff, Christopher Burant, and Stuart Youngner (2004) was to find out more about what the general public understands and believes about when a person is dead. More specifically, the study tried to determine (...) how members of the public define death, especially their acceptance and interpretation of the medical concept of "brain death," and their attitudes toward the so-called "dead donor rule," an informal but powerful social and legal norm insisting that the taking of organs for transplantation not cause the death of the source of those organs.As the demand for organs increases and the waiting list grows, the United States has explored multiple ways to expand the pool of potential donors. One approach has been to gerrymander (coherently or not) the line between life and death to shift patients who are extremely compromised but traditionally considered to be in the living category into the dead category. In this way, the dead donor rule remains technically intact. This reasoning is explicit in the report of the Harvard Medical School Ad Hoc Committee (1968) that "introduced" "brain death" to the American culture. Since then, other efforts to redraw the line have been proposed and rejected.One alternative to gerrymandering is to consider under what conditions, if any, it is morally acceptable to violate the dead donor rule. Some would argue that this alternative is the more "honest" approach. Rather than sidestepping moral problems by calling people dead, it brings the moral problems to the surface where the necessity of sticking to the rule can be considered on its own merits. However, when the Journal of the American Medical Association printed a position paper that proposed making anencepahlic newborns an exception to the dead donor rule, along with arguments about why this was acceptable, the outcry was so great that the proposal was retracted (AMA 1995).Clearly, our society has identified organ transplantation as a priority, although two papers in this volume (those by Courtney Campbell and by Megan Crowley-Matoka and Robert Arnold) take issue with that prioritization. The fact that the donor pool has remained relatively stable (and inadequate) despite massive efforts [End Page 211] to increase it speaks, at least in part, to the cultural and legal resistance to "new" ways to procure more organs. Voluntarism seems to have peaked. Financial incentives clash with the heavily endorsed notion of the "gift of life" and seem to many to violate the dignity of the human body. Presumed consent or eminent domain, in which the community has a greater claim to a person's organs than that person or his/her family, go against the grain of American individual freedom and the ethos of patient autonomy.Abandoning the dead donor rule generally is regarded as an even tougher sell to the American public and its legislators. The study by Siminoff and colleagues attempts, among other things, to gauge just how tough this sell would be. What the data actually demonstrate is a matter of interpretation, and this issue of the KIEJ is devoted to some of those interpretations. The authors, with the exception of Daniel Hausman, came together for a meeting in Cleveland, Ohio, during which the study's methods and data were presented with time for questions, clarifications, and general discussion. The authors then worked with the editors to generate the papers printed in this volume.The issue begins with a presentation of the study conducted by Siminoff and colleagues. The same paper also appears in the journal Social Science and Medicine, where it includes the conclusions of the authors (Siminoff, Burant, and Youngner 2004). In the current volume, we present only the methodology of and data from the study, allowing a number of distinguished commentators to offer their own conclusions and reflections.The first response comes from Tracy Schmidt, Executive Director of Intermountain Donor Services, one of our nation's organ procurement organizations (OPOs). For years, organ procurement professionals have reported anecdotal stories about families who wished to donate organs of... (shrink)

Teaching medical ethics and law to medical students has been a requirement for all medical schools in the United Kingdom since the General Medical Council’s Tomorrow’s Doctors guidance on medical curricular reform of 1992. All United Kingdom medical schools now have at least some medical ethics and law in their curricula and most have a person appointed primarily to be responsible for this teaching. Since the publication in the Journal of (...) Medical Ethics in 1998, volume 24, pages188–192, of a consensus statement on a core curriculum in medical ethics and law for medical students, most medical schools have gradually come to conform to this as the benchmark for the content of such teaching. There remains, however, a great diversity in the approaches taken to ensuring that learning this content takes place. A wide range of strategies have …. (shrink)

The main causes of suicide and how suicide could and should be prevented are ongoing controversies in the scientific literature as well as in public media. In the bill on public health from 2008, the Swedish Parliament adopted an overarching “Vision Zero for Suicide” and nine strategies for suicide prevention. However, how the VZ should be interpreted in healthcare is unclear. The VZ has been criticized both from a philosophical perspective and against the background of clinical experience and alleged empirical (...) claims regarding the consequences of regulating suicide prevention. This study is part of a larger research project in medical ethics with the overarching aim to explore whether the VZ is ethically justifiable. The aim is to enrich the normative discussion by investigating empirically how the VZ is perceived in healthcare. Interviews based on a semi-structured interview guide were performed with 12 Swedish psychiatrists. The interviews were analysed with descriptive qualitative content analysis aiming for identifying perceptions of the Vision Zero for Suicide as well as arguments for and against it. Though most of the participants mentioned at least some potential benefit of the Vision Zero for Suicide, the overall impression was a predominant skepticism. Some participants focused on why they consider the VZ to be unachievable, while others focused more on its potential consequences and normative implications. The VZ was perceived to be impossible to realize, nonconstructive or potentially counterproductive, and undesirable because of potential conflicts with other values and interests of patients as well as the general public. There were also important notions of the VZ having negative consequences for the working conditions of psychiatrists in Sweden, in increasing their work-related anxiety and thwarting the patient-physician relationship. (shrink)

In 2002, I wrote an editorial in this Journal arguing that it was time to review the structure and function of ethics committees in the USA, Australia and the UK.1 This followed the deaths of Ellen Roche and Jesse Gelsinger, which were at least in significant part due to the poor functioning of research ethics committees in the USA.2 In the case of Ellen Roche, it was the failure to require a systematic review of the existing (...) literature which led to her death. Iain Chalmers and I had previously documented in 1996 the failure of ethics committees to require systematic review.3 In 1998, at the time of revising the previous guidelines and forming the first Australian National Statement on Research Ethics, I made a public submission to the Australian Health Ethics Committee arguing that the new guidelines for RECs should include a person with skills in conducting systematic reviews of the literature and that the requirement to have a religious representative on the committee be replaced with the requirement to have an ethicist. Neither of these changes was made. I argued, ‘It is time to ask whether institutional RECs should be abandoned in favour of expert committees that cover many institutions—suprainstitutional specialist committees. Supraregional specialist ethics committees could specialise—for example, in genetic research, cancer clinical trials, dermatology, respiratory physiology and each of the specialist areas of medical research. An example of such a committee is provided by the Thoracic Society of Australia and New Zealand research ethics committee, which reviews multicentre trials of respiratory drugs’.4 Around that time, I was involved ‘at the coal face’ as Chair of the Department of Human Services Ethics Committee in Victoria. In a public presentation, I arguedThere are two philosophical views of what ethics review is. On the …. (shrink)

Although telepsychiatry consultations have been tried and tested for several years, at least in relatively limited numbers and settings, the current COVID-19 pandemic has caused an exponential increase in their application. Even as lockdown restrictions were lifted and a return to face-to-face consultations was possible, many practitioners and patients decided to uphold teleconsultations for some or a large part of their interactions. This was mostly driven by the exceptional circumstances of the pandemic, as ongoing safety concerns, the need (...) for PPE use and uncertainty around whether face-to-face meetings could go ahead continued to form barriers to usual care practices. Frittgen and Haltaufderheide aptly hypothesise that extensive changes in online communication behaviour will also impact ethical aspects of the therapeutic relationship.1 After considering how the use of technology may affect the therapeutic relationship in video-based consultations, they provide an ethical analysis of this impact along four dimensions: respect for autonomy, lucidity, fidelity and humanity.1 In this commentary I will have a look at the difference between crisis standards of care and usual care, the need to consider specific patient needs in teleconsultation use, the importance of justice understood as equity and access to technology, and a major challenge ahead. Throughout history, crisis situations have often been major catalysts of technological and other progress. Under challenging …. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Religion and the Body in Medical ResearchCourtney S. Campbell (bio)AbstractReligious discussion of human organs and tissues has concentrated largely on donation for therapeutic purposes. The retrieval and use of human tissue samples in diagnostic, research, and education contexts have, by contrast, received very little direct theological attention. Initially undertaken at the behest of the National Bioethics Advisory Commission, this essay seeks to explore the theological and religious questions (...) embedded in nontherapeutic use of human tissue. It finds that the “donation paradigm” typically invoked in religious discourse to justify uses of the body for therapeutic reasons is inadequate in the context of nontherapeutic research, while the “resource paradigm” implicit in scientific discourse presumes a reductionist account of the body that runs contrary to important religious values about embodiment. The essay proposes a “contribution paradigm” that provides a religious perspective within which research on human tissue can be both justified and limited.The retrieval and use of human tissue samples for diagnostic, therapeutic, research, and educational purposes represent further developments in scientific study of the human body as a source of medical information. Following the completion of its examination of the ethical and policy issues pertaining to human cloning in the spring of 1997, the National Bioethics Advisory Commission (NBAC) returned to the set of questions for which it had been originally constituted, including ethical issues that arise in human subjects research. One issue that proved controversial for the human genetics subcommittee of NBAC was the scientific, philosophical, and legal status of tissue and other body parts (usually surgical specimens) that had been retrieved from patients (not research subjects) who had given general consent to the use of their body materials for research and educational purposes. The subcommittee addressed questions about the adequacy of general versus specific [End Page 275] consent, the scientific merits of identifiable versus anonymous samples and claims about patient confidentiality, and the justification for patient refusals and requests that the materials be returned to the patient or discarded rather than made available for scientific research. In an effort to better understand the ramifications of research on human tissue, the subcommittee commissioned several background papers that examined these questions from ethical, legal, research, and religious perspectives. What follows is a modified version of the report on religious considerations originally presented to the genetics subcommittee of NBAC.The central question examined in this article is whether tissue banking for purposes of research presents distinctive theological issues or prompts objections from religious communities or scholars. Religious discussion of human organs and tissues has focused largely on donation for therapeutic purposes (what I describe as the “donation paradigm”); hence, there is very little direct consideration of nontherapeutic uses of such tissue. It is possible, however, to describe implications and suggest inferences by considering (1) religious attitudes to the human body and to organs, tissues, and cells removed from the body, and (2) religious discussions of modes of transfer of body parts, such as donations, offerings, sales, and abandonment. By and large, this discussion will reflect themes that emerge from the central Western religious traditions, with some attention given to Eastern and Native perspectives.The Body: Religious Holism, Scientific Reductionism, Private PropertyThe human body as an organic totality has long been the subject of theological reflection and a symbol for religious communities. However, much less attention has been devoted to the religious status of organs, tissues, cells, and DNA. The reflection of religious scholars and communities on the status of body parts has been prompted by the necessity to confront practical questions in personal and public health and in communal life, such as justifications for surgery, autopsies, organ donation, or burial. Scientific and research interest in parts of the body can sometimes conflict with religious values about bodily integrity. Indeed, E. Richard Gold cites the “disparate claims of scientific investigation and religious belief on the body” as the exemplary case of incommensurate values regarding the body. According to Gold (1996, p. 149), “The body, from a scientific viewpoint, is a source of knowledge of physical development, aging, and disease. From a religious perspective, the body is understood [End Page 276] as a sacred object, being created in the image... (shrink)

Photo ID 71252867© Stepan Popov| Dreamstime.com Abstract While Medical Assistance in Dying (MAiD) has been legalized in Canada since 2016, it still excludes eligibility for persons who have mental illness as a sole underlying medical condition. This temporary exclusion was set to expire on March 17th, 2024, but was set 3 years further back by the Government of Canada to March 17th, 2027. This paper presents a critical appraisal of the case of MAiD for individuals with mental illness (...) as the sole underlying medical condition through the analysis of three ethical theories: principlism, deontology, and utilitarianism. Through evidence and discussion, it will be demonstrated that MAiD, in this context, may be ethically justifiable on the grounds of upholding human rights, protecting dignity, and minimizing suffering. Introduction In June of 2016, Medical Assistance in Dying (MAiD) was legalized in Canada.[1] Throughout the first six years, a temporary exclusion of eligibility for persons suffering solely from mental illness was extended.[2] The exclusion of mental illness as a sole underlying medical condition was set to expire on March 17, 2024.[3] However, on February 1, 2024, just over a month before the set expiration, the Government of Canada once again extended the exclusion, this time setting it back three years to March 17, 2027. There are currently several countries that allow MAiD for mental illness, including Belgium, the Netherlands, and Luxembourg.[4] Some countries, like Spain,[5] do not give specific guidance, leaving the matter under discussion by ethicists and courts. In these countries, there are specific (although different) requirements for the process; overall, for mental illness, the illness must be verifiable and not simply related to a perception of satisfaction with the length of life. This extension ignited discussion on whether MAiD for persons who have mental illness as a sole underlying medical condition in Canada is ethically acceptable. As a complex, multi-faceted, and interdisciplinary issue, ethicists assessing MAiD must take into account various moral obligations and considerations. This paper analyses MAiD in this context through the application of three ethical theories: principlism, deontology, and utilitarianism. This paper concludes that, based on the current evidence and knowledge of this developing situation, MAiD for persons with mental illness in Canada may be ethically justified on the grounds of upholding human rights, labour obligations, and dignity. Through the exploration of research and discussions, it will be demonstrated that society at large ought to protect liberty and act towards relieving suffering, thereby supporting the potential eligibility of MAiD for persons who have mental illness. Principlism: The Capacity and Ability to Assess and Decide for One’s Own Life Principlism is the application of four principles: autonomy, beneficence, non-maleficence, and justice. Principlism supports permitting MAiD for mental illness due to the importance of autonomy in decision-making, equitable and just practices for MAiD assessors, and reducing suffering for patients and their family member(s) and/or friend(s). Carter v. Canada, the Canadian Supreme Court ruling of 2015—which changed Canadian law to allow for MAiD—held that the prohibition of MAiD infringed on Canadians’ right to “life, liberty, and the security of the person.” In a unanimous decision, the Supreme Court of Canada decided that the criminal prohibition of MAiD violates the Canadian Charter of Rights and Freedoms.[6] The Court concluded that the criminal law prohibiting MAiD interfered with people’s autonomy and dignity, which are protected by the rights of liberty and security of the person.[7] The ruling emphasized that Canada’s constitution reflects the fundamental importance of individual autonomy in personal decision-making. Research provides evidence that MAiD improves autonomy: A study among psychiatric patients found that 8 of 48 psychiatric patients said the mere option of accessing MAiD was enough to assess their future options for living wholly.[8] These findings complement a study entailing interviews with 30 adults who have mental illness, which emphasized that the ability to access MAiD allows individuals to analyze their quality of life, envision their desired future, and make decisions accordingly.[9] Although not all participants agreed that mental illness as the only underlying medical condition was appropriate for MAiD eligibility, many participants agreed that patient autonomy in decision-making was paramount and should be respected. However, autonomy as an ethical principle does not immediately grant all persons with mental illness the option to access MAiD. There are multiple eligibility criteria for those who wish to receive MAiD, which still must be approved and assessed. Currently, eligibility criteria for MAiD states that individuals must “give informed consent to receive MAiD, meaning that the person has consented to receiving MAiD after they have received all information needed to make this decision.”[10] Consent requires capability or capacity, which is the ability to understand relevant information, appreciate its potential consequences, and make an informed decision for oneself.[11] Like for many other diseases, disabilities, and conditions, patient capability is determined on a case-by-case basis.[12] Given the stigma surrounding those struggling with mental health, this thorough case-by-case examination of an individual patient’s capability and capacity without prejudice or partiality should lead to equitable and fair treatment. Without appropriate testing, those with mental illness could be wrongly stripped of their decision-making power. Arguments against MAiD for those with mental illness have raised concerns about the potential for individuals to harm themselves and others. A survey of MAiD providers demonstrated that physicians believed that the bereavement experience following MAiD is challenging and profoundly distinct and that bereavement support for all members involved should be required.[13] However, while watching one die (of MAiD) may cause harm to their families, friends, and support system at large, it is also important to recognize that watching someone suffer and struggle through their mental health journey also poses significant harm. Qualitative studies in Ontario, Canada, have interviewed family members of persons with mental illness as a sole medical condition, and interviewees shared that witnessing the illness and its impacts on their close one's lives was a very difficult experience.[14] As it relates to MAiD, participants emphasized that those living with mental illness are in the best position to understand their own pain and suffering and, in turn, make their own decisions about relief.[15] In an interview, a MAiD provider stated that MAiD may provide less suffering and more peace, and that, although it “depends on the family,... usually the family is more prepared and at peace.”[16] On the contrary, a person who has mental illness may perceive choosing MAiD as beneficial to their family member(s) and/or friend(s). Among those who died by MAiD in 2021, 35.7 percent reported that they perceived themselves as a burden on their family and friends.[17] While some authors report their concerns regarding such social burden as a potential driving factor for MAiD requests, others report that there are other additional burdens associated with requesting MAiD that may be financial, societal, and personal.[18] As such, the extension of MAiD eligibility to those with mental illness will likely only allow a small number of people to be granted MAiD.[19] Many others will be diverted to appropriate services and treatments. Patients’ decision to choose MAID noted their ability to make choices about their own care, reflecting the value of autonomy.[20] Although it is difficult to determine what is good for families in individual cases, MAiD presents an option that is both beneficent and non-maleficent. Therefore, these arguments satisfy the principles which do not necessarily conflict with MAiD. Deontology: The Duty to Recognize Vulnerability and Relieve Suffering The argument here begins with the fundamental focus of deontology—that moral duty lies in an action rather than in its consequences. Further discussion is required to analyze the impact of MAiD on healthcare workers. The Canadian Medical Association (CMA) Code of Ethics and Professionalism requires physicians to abide by virtues, commitments, and responsibilities in delivering health care and service.[21] The code states that “a compassionate physician recognizes suffering and vulnerability, … and alleviate[s] the patient’s suffering.”[22] In the context of MAiD for persons with mental illness as a sole underlying medical condition, vulnerabilities could be wide in range. Many Canadians are concerned with the interaction between mental health and other social determinants of health, such as the lack of medical, disability, financial, housing, and social support and resources.[23] As a result, another layer to the ethical issue arises: Does permitting MAiD for mental illness treat the symptoms of the issue rather than the root problem itself (social, economic, and systemic inequities)? Some argue against MAiD, stating that the nation should first focus on developing better quality care and service.[24] Others support MAiD as a potential harm reduction approach, given that most of these unjust conditions require a higher level of long-term structural and public policy overhaul.[25] The CMA Code also calls upon physicians to recognize and alleviate patients’ suffering. Some argue that while physicians and medical professionals do work to relieve suffering, they are trained to do so through a primary care-based diagnose-and-treat approach.[26] Studies that have captured Canadian physicians’ experiences providing MAiD report that, although physicians stated that the work was rewarding, it came with many challenges, including strained relationships with coworkers, increased workload, and inadequate compensation.[27] Physicians report that a part of the problem is that MAiD rules are written by lawyers and experts who are removed from its reality in medical practice. As a result, there is a lack of clarity surrounding practice norms and a lack of support for physicians.[28] Thus, while healthcare practitioners have a duty to relieve patients’ suffering, they should feel adequately trained and supported in doing so. If physicians and healthcare professionals recognize vulnerability and relieve suffering, then they should act accordingly, regardless of potential associations or outcomes. Making persons with mental illness eligible for MAiD ensures that treatment to relieve their suffering is available. However, it is imperative that there are sufficient resources and support available to healthcare professionals to ensure that they feel prepared and supported to provide MAiD, should they wish to do so. Utilitarianism: Minimizing Intolerable Suffering and Dying with Dignity Overall, utilitarianism is largely concerned with the greatest happiness principle—to increase the amount of happiness for the greatest number of people. So far, this paper has analyzed individual, family, and practitioner-based ethical considerations. But if MAiD were to be extended to those with mental illness as a singular underlying medical condition, what implications would this have for the world and society at large? There is a global drive toward authorizing organized ending of life, with an increasing number of countries legalizing MAiD.[29] The medical system is generally seen as a safe and appropriate system to carry out MAiD, especially when suicide and self-harm are regarded as “alternatives.” Yet despite these worldwide efforts, many argue through the theory of utilitarianism that the inability to see long-term consequences renders MAiD a premature solution, particularly for those who are unable or unwilling to seek other forms of potentially healing treatment or for those who may undergo MAiD only for a technological innovation or biomedical advancement to later come along as a potential cure.[30] While it is true that MAiD does not prevent these “premature deaths,” it is also true that it does not claim to.[31] MAiD provides an option to alleviate intolerable suffering. Some individuals with severe mental illness do describe their condition as intolerable suffering. MAiD is seen as an option to minimize suffering. It can also be seen as a way to die with dignity and relief.[32] While predicting outcomes is difficult, extending MAiD eligibility for persons experiencing mental illness does not undermine its ability to end suffering. It allows eligible individuals to take charge of their health, their life, and their future. Conclusion Based on the current evidence, allowing MAiD for persons with mental illness as their sole underlying medical condition presents as an ethically justifiable action. The right to self-determination and fair accessibility demonstrates that there is more harm done by prohibiting MAiD for mental illness than allowing it. Such liberty is a right, and in the context of relieving suffering, it is a duty that healthcare workers must uphold, although the ability to opt out of providing MAiD is well established. Thus, to recognize vulnerability and relieve suffering means to provide methods, such as MAiD, for those deeply impacted by mental illness. These justifications stand at both the individual level and for society at large. Nevertheless, it remains imperative to take an upstream approach that addresses the social determinants of health and aims to prevent mental illness and promote long-term, beneficial social change for those suffering, struggling, and vulnerable in our communities. - [1] Jaro Kotalik and David W. Shannon, Medical Assistance in Dying (MAID) in Canada Key Multidisciplinary Perspectives, 1st ed. 2023., The International Library of Bioethics, 104 (Cham: Springer International Publishing, 2023), https://doi.org/10.1007/978-3-031-30002-8. [2] Department of Justice Government of Canada, “Canada’s Medical Assistance in Dying (MAID) Law,” February 21, 2024, https://www.justice.gc.ca/eng/cj-jp/ad-am/bk-di.html. [3] Health Canada, “Final Report of the Expert Panel on MAiD and Mental Illness,” transparency - other, May 13, 2022, https://www.canada.ca/en/health-canada/corporate/about-health-canada/public-engagement/external-advi sory-bodies/expert-panel-maid-mental-illness/final-report-expert-panel-maid-mental-illness.html. [4] Federal Public Service (FPS) Health Belgium, “Federal Commission for the Control and Evaluation of Euthanasia,” n.d., https://consultativebodies.health.belgium.be/en/advisory-and-consultative-bodies/federal-commission- control-and-evaluation-euthanasia.; Government of Netherlands, “Is Euthanasia Allowed in the Netherlands?,” n.d., https://www.government.nl/topics/euthanasia/is-euthanasia-allowed.; “Information on Requesting Euthanasia or Assisted Suicide,” n.d., https://guichet.public.lu/en/citoyens/sante/fin-vie/euthanasie/euthanasie-assistance-suicide.html. [5] Luis Espericueta, First official report on euthanasia in Spain: A comparison with the Canadian and New Zealand experiences, Medicina Clínica (English Edition), Volume 161, Issue 10, 2023, Pages 445-447, ISSN 2387-0206, https://doi.org/10.1016/j.medcle.2023.06.021. [6] Government of Canada, “The Canadian Charter of Rights and Freedoms,” March 15, 2021, https://www.justice.gc.ca/eng/csj-sjc/rfc-dlc/ccrf-ccdl/. [7] Supreme Court of Canada, “Carter v. Canada,” Constitutional Law, 2015, https://scc-csc.lexum.com/scc-csc/scc-csc/en/item/14637/index.do.; Kotalik and Shannon, Medical Assistance in Dying (MAID) in Canada Key Multidisciplinary Perspectives. [8] Karandeep Sonu Gaind, “What Does ‘Irremediability’ in Mental Illness Mean?,” Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie 65, no. 9 (September 2020): 604–6, https://doi.org/10.1177/0706743720928656; Lieve Thienpont et al., “Euthanasia Requests, Procedures and Outcomes for 100 Belgian Patients Suffering from Psychiatric Disorders: A Retrospective, Descriptive Study,” BMJ Open 5, no. 7 (July 27, 2015): e007454, https://doi.org/10.1136/bmjopen-2014-007454. [9] Hamer Bastidas-Bilbao et al., “Walking Alongside: Views of Family Members on Medical Assistance in Dying for Mental Illness as the Sole Underlying Medical Condition,” Qualitative Health Research 33 (September 29, 2023), https://doi.org/10.1177/10497323231197365. [10] Government of Canada, “Canada’s Medical Assistance in Dying (MAID) Law.” [11] Commission sur les soins de fin de vie, “Les conditions de l’admissibilité à l’aide médicale à mourir au Québec: la constance dans l’évolution de la loi concernant les soins de fin de vie,” June 9, 2023, https://csfv.gouv.qc.ca/ fileadmin/docs/autres_rapports/csfv_lcsfv_conditions_ amm_2023-06-29.pdf.; Trudo Lemmens, “When Death Becomes Therapy: Canada’s Troubling Normalization of Health Care Provider Ending of Life,” The American Journal of Bioethics 23, no. 11 (November 2, 2023): 79–84, https://doi.org/10.1080/15265161.2023.2265265. [12] Justine Dembo, Udo Schuklenk, and Jonathan Reggler, “‘For Their Own Good’: A Response to Popular Arguments Against Permitting Medical Assistance in Dying (MAID) Where Mental Illness Is the Sole Underlying Condition,” Canadian Journal of Psychiatry. Revue Canadienne De Psychiatrie 63, no. 7 (July 2018): 451–56, https://doi.org/10.1177/0706743718766055. [13] Konia Trouton et al., “Attitudes and Expectations Regarding Bereavement Support for Patients, Family Members, and Friends: Findings from a Survey of MAID Providers,” British Columbia Medical Journal 62, no. 1 (2020). [14] Bastidas-Bilbao et al., “Walking Alongside.” [15] Bastidas-Bilbao et al. [16] Trouton et al., “Attitudes and Expectations Regarding Bereavement Support for Patients, Family Members, and Friends: Findings from a Survey of MAID Providers,” 2020. [17] Ramona Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” Palliative & Supportive Care 21, no. 5 (October 2023): 871–78, https://doi.org/10.1017/S1478951523001025; Health Canada, “Third Annual Report on Medical Assistance in Dying in Canada 2021,” report on plans and priorities;transparency - other, July 26, 2022, https://www.canada.ca/en/health-canada/services/publications/health-system-services/annual-report-medical-assistance-dying-2021.html; Lemmens, “When Death Becomes Therapy.” [18] Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” October 2023.; Bastidas-Bilbao et al., “Walking Alongside.” [19] Olivia Stefanovich, “Opposition Parties Call for Indefinite Pause to MAID Expansion for Mental Illness | CBC News,” Canadian Broadcasting Corporation, January 28, 2024, https://www.cbc.ca/news/politics/special-joint-committee-maid-mental-illness-report-1.7095679; Benjamin Lopez Steven, “Number of Assisted Deaths Jumped More than 30 per Cent in 2022, Report Says | CBC News,” Canadian Broadcasting Corporation, October 27, 2023, https://www.cbc.ca/news/politics/maid-canada-report-2022-1.7009704. [20] Hamer Bastidas-Bilbao et al., “Searching for Relief from Suffering: A Patient-Oriented Qualitative Study on Medical Assistance in Dying for Mental Illness as the Sole Underlying Medical Condition,” Social Science & Medicine 331 (August 1, 2023): 116075, https://doi.org/10.1016/j.socscimed.2023.116075. [21] Canadian Medical Association, “Canadian Medical Association Code of Ethics and Professionalism” (Canada: Canadian Medical Association, December 8, 2018), https://policybase.cma.ca/link/policy13937. [22] Canadian Medical Association. [23] Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” October 2023; Stefanovich, “Opposition Parties Call for Indefinite Pause to MAID Expansion for Mental Illness | CBC News.” [24] John Paul Tasker, “Liberal Government Promoting a ‘culture of Death’ with Medical Assistance in Dying Law, Conservative MP Says | CBC News,” Canadian Broadcasting Corporation, March 6, 2023, https://www.cbc.ca/news/politics/culture-of-death-medical-assistance-in-dying-mental-illness-1.6769504. [25] Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” October 2023; Kayla Wiebe and Amy Mullin, “Choosing Death in Unjust Conditions: Hope, Autonomy and Harm Reduction,” Journal of Medical Ethics, April 26, 2023, https://doi.org/10.1136/jme-2022-108871. [26] Ramona Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” Palliative & Supportive Care 21, no. 5 (October 2023): 871–78, https://doi.org/10.1017/S1478951523001025. [27] Konia Trouton et al., “Attitudes and Expectations Regarding Bereavement Support for Patients, Family Members, and Friends: Findings from a Survey of MAID Providers,” British Columbia Medical Journal 62, no. 1 (2020), https://bcmj.org/articles/attitudes-and-expectations-regarding-bereavement-support-patients-family-m embers-and.; William Robert Nielsen, “MAiD in Canada: Ethical Considerations in Medical Assistance in Dying,” Canadian Journal of Bioethics 4, no. 2 (December 9, 2021): 93–98, https://doi.org/10.7202/1084456ar. [28] Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” October 2023. [29] Lemmens, “When Death Becomes Therapy.” [30] William Robert Nielsen, “MAiD in Canada: Ethical Considerations in Medical Assistance in Dying,” Canadian Journal of Bioethics 4, no. 2 (December 1, 2021): 93–98, https://doi.org/10.7202/1084456ar. [31] Steven, “Number of Assisted Deaths Jumped More than 30 per Cent in 2022, Report Says | CBC News.” [32] A. Plaisance et al., “Quebec Population Highly Supportive of Extending Medical Aid in Dying to Incapacitated Persons and People Suffering Only from a Mental Illness: Content Analysis of Attitudes and Representations,” Ethics, Medicine and Public Health 21 (April 1, 2022): 100759, https://doi.org/10.1016/j.jemep.2022.100759. (shrink)

Much has been written about the importance of narrative in teaching ethics and humanities to medical students and residents, as well as the value of narratives in clinical care. Relatively little has been said about the essential role of narrative in bioethics consultations. For most consults, the interpretation of narratives is the central moral feature, and the ethics consultant is inevitably one of the narrators. In a recent consult in which I participated, at least three narratives (...) were in play. The medical record itself was a narrative, or really, a variety of narratives. A second distinct narrative was the story of why this case had come to be categorized as an ethical concern for the medical team. A third narrative was the tentative sketch running through my mind as a consultant‐partly factual, partly anticipatory and conjectural, inevitably personal‐about what was going on here. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Past and Future of Environmental Ethics/PhilosophyBryan Norton (bio)About 15 years ago, at one of the first meetings of the group known as the International Society for Environmental Ethics (ISEE) at American Philosophical Association (APA) meetings, I drew an analogy with the field of medical ethics, arguing that environmental ethicists should look beyond philosophy departments and seek liaisons with Schools of Forestry, Schools of Marine (...) Science, and Environmental Studies Programs, and that philosophers should take a more active role in policy discussions and process. At that time, I was actively engaged in the actual policy processes, at the Environmental Protection Agency and other agencies, and perceived that: (a) These agencies desperately needed the kinds of conceptual and normative analysis philosophers could provide; but that (b) Practitioners of environmental policy did not find that the categories and concepts of traditional "metaphysical" approaches to environmental value provided them with useful guidance in policy decision making.My urging gained me some heavy criticism, and even made me some enemies, as leading members of the environmental ethics establishment openly complained that my judgment—in seeing philosophy of environmental protection as needing a basis in analysis of possible actions—had been compromised by "spending too much time inside the beltway."Since those early years, I have watched my colleagues in environmental ethics debate this point, but mainly as a sideline to their metaphysical speculation.In the meantime, my colleagues in medical ethics have populated medical schools, formed liaisons with medical research institutions, and become regular commentators on newscasts about ethically controversial medical issues. Meanwhile, Chris Stone, the legal scholar, had his students do a word search of the Congressional Record over several years, and found almost no references to "environmental ethics."As I see it, there are three differences between the environmental ethics and the medical ethics cases: (1) Philosophers have responded to medical issues by engaging practitioners, while most environmental ethicists have become, at best, "token" members of philosophy departments and, whereas medical ethics practitioners tend to talk about decision criteria [End Page 134] ("informed consent", etc.), environmental ethicist continue to concentrate on the metaphysical foundations of environmental values; (2) The medical profession, beset with public controversies, recognized the need for more ethical discourse about medical choices, and actively embraced philosophers in their programs, whereas most environmental practioners cannot see how philosophical analysis will help them to make better decisions; and (3) Being much wealthier than environmentalists, the medical schools and professionals were able to initiate positions and offer financial support, while environmental ethicists have to compete with other environmental researchers and commentators for small pots of funding.While we can't do much about (3), we can, I assert, do a lot more about (1) and (2). With respect to philosophy departments, the trend may be(and in my view should be) toward developing joint appointments between philosophy departments and policy schools, forestry schools, and environmental studies programs. This will bring philosophers and students into more direct contact with real problems and the language of decision making, rather than metaphysics. And with respect to point (2), I continue to urge environmental philosophers to address real problems, rather than operating on an abstract level and then finding "applications" of these abstractions.Philosophers, in other words, should become more "pragmatic" in their approach to both policy and philosophy. One aspect of this move is the need—after years of thinking of environmental philosophy as environmental ethics—to concentrate on epistemological, not metaphysical, aspects of environmental science and decision making.Let me expand on this last point, because it seems to me to be the most important consideration affecting the future of environmental ethics, at least in the short and medium run. I think the central debates about whether nonhumans have "intrinsic value" will be (and should be) replaced with a vigorous discussion of the epistemology of all environmental values. Recently, two leading environmental philosophers, Baird Callicott and Mark Sagoff, have strongly endorsed what would traditionally be called "non-naturalist" approaches to the epistemology of environmental ethics. For Sagoff, this involved positing "ethical and aesthetic" facts which should guide environmental policy discourse away from any discussion of the utilitarian benefits of an improved... (shrink)

Chapter 1: An Introduction: The ‘Semantic Sting’ Argument Describes Dworkin’s theory as concerning the conditions of legal validity. “A legal system is a system of norms. Validity is a logical property of norms in a way akin to that in which truth is a logical property of propositions. A statement about the law is true if and only if the norm it purports to describe is a valid legal norm…It follows that there must be certain conditions which render certain norms, (...) but not others, legally valid. Hence it also follows that there can be two types of disagreement over the truth or falsehood of propositions about the law. People can disagree over the question ‘What are the conditions of legal validity?’, in which case their disagreement is a theoretical one. Or they can agree on the conditions of validity, and disagree as to whether or not those conditions actually obtain in a given case or not.” Argues that the best way to interpret Dworkin’s ‘semantic-sting argument’ is as a general argument against conventionalism in legal positivism. Summarizes the outcome of Dworkin’s argument as follows: “[I]f Dworkin is right about the legal reasoning of lawyers and judges, conventionalism would be self-defeating: if lawyers and judges recognize as legally binding not only those norms which are uncontroversially identifiable under the Rule of Recognition, that is, if what they recognize as binding is not only source-based law, then conventionalism turns out to be false on its own terms. In other words, either law is not what lawyers and judges think that it is, in which case law is not a matter of conventions, or – if it is what lawyers and judges think – conventionalism is false, as they do not see the law as purely a matter of conventions.” Dworkin’s theory, then, is a new conception of jurisprudence aiming to present itself as a rival to conventionalism. The book will be concerned with re-examining positivism in light of the interpretative challenge. Chapter 2: Meaning and Interpretation “[R]oughly, interpretation can be defined as an understanding or explanation of the meaning of an object.” Interpretation in this narrow sense is distinct from a less formal and broader use of interpretation that makes it equivalent to explanation. “Hence also, only those objects which are capable of bearing some meaning qualify as objects of interpretation.” [Why shouldn’t we think of interpretation as object-identification? This seems to be closer to what Dworkin has in mind.] Thus, a consideration of the philosophical work on meaning is appropriate. First, a consideration of Davidson on interpretation. The thesis is that Davidson’s “radical interpretation” can only account for sentence meaning and not for linguistic interpretation in general. Davidson cannot account for the non-rule-governed aspects of communication. “Semantics, as opposed to interpretation, concerns those aspects of communication which are rule or convention governed…but such rules are normally unavailable as reasons or justifications for an interpretation. On the contrary, interpretation is usually required because the issue is not determined by rules or conventions.” Interpretation, rather, is parasitic with understanding the meaning of an expression and not equivalent with it. As Dummett notes, any reflection on the meanings of words assumes prior knowledge of ordinary meanings. “This leads to the conclusion that understanding or explaining the meaning of an expression and interpreting it, are two conceptually separate things. It also indicates that seman ics can only be employed, if at all, to elucidate the concept of interpretation by way of contrast: interpretation concerns those aspects of communication which are under-determined by semantic rules or conventions.” Pragmatics, the study of problems posed by discrepancies between utterer’s meaning and sentence meaning, would seem to be closer to inquiry into interpretation. Both are concerned with understanding how meaning is possible where conventional rules leave off. Contemporary pragmatics, moreover, recognizes the logically indeterminate character of communicative inferences beyond conventional meaning and that the contextual conditions that account for the possibility cannot be realized in the semantic structure of the sentence. However, different criteria of success may be at work in pragmatics than interpretation. Pragmatics is concerned with how communication is achieved and thus the criteria of success would be grasping a speaker’s intentions. Many think, however, that communication is unimportant in certain spheres of communication, e.g. artistic interpretation, and that in these cases the aim of interpretation is not to uncover the actual artist’s intentions. What kind of meaning is interpretation aimed at then? It cannot be the meaning the object has for the interpreter. “Interpretation purports to be a statement about the object interpreted, not about the subject who offers the interpretation…it is crucial to remember that not everything we say about a work of art, or any other text, amounts to an interpretation of it. Only those aspects of a text which can shed light on its meaning form part of the text’s interpretation. What the text means for someone rarely entails anything about what the text means.” [This is puzzling to some extent for it remains somewhat ambiguous what it means to talk of subject-independent meaning.] Interpretive meaning attribution is, rather, counterfactual. “In general, I will suggest that the answer to this question consists in the fact that meaning is assigned by a counterfactual statement. Given that x is the meaning attributed to, for instance a text T, and x is not the literal meaning of T, nor is it the meaning of T intended by its author, then the attribution of meaning x to T can only be understood as the contention that on the basis of certain assumptions a certain fictitious or stipulated speaker would have meant x by expressing T.” Thus, on this account, interpretation, when it does not concern an actual speaker, turns out to be a kind of counterfactual intention attribution. Twofold point: “First, that interpretation is essentially a matter of attributing intentions, that is, in the pragmatics sense of ‘meaning’, namely, meaning that such-and-such by an act or expression. At the same time, interpretations need not be based on the intentions of actual authors; the meaning of an act or expression is understandable in terms of counterfactual intentions.” [Are we really restricted to understanding the coherence and integrity of meaning in such a way? Presumably the author is a kind of device for organizing meaning, much like Dworkin’s integrity, but need it take that format?] The logic of interpretation is typically reducible to intention attribution. [What role does the counterfactual author play in structuring meaning?] The criteria of interpretive success will depend upon the object, whether it is the real author or the counterfactual author. If the former, success will depend upon the retrieval of the author’s actual intentions. “Likewise, if the author is characterized in terms of some ideal representative of a certain genre, for instance, the presumptions which are taken to determine this c aracterization would provide the criteria of success for the particular interpretation offered.” [The criteria of success would seem, then, to be the principles, ideals, etc. that we attribute to the counterfactual author. These attributed qualities would be doing all the work – is the attribution of intention to the hypothetical author, then, really necessary at all?] [Does this account presuppose a weird dichotomy between what an object is and what it means? This dichotomy is different, if present at all, in Dworkin.] Chapter 3: Dworkin’s Theory of Interpretation and the Nature of Jurisprudence Three main insights of Dworkin’s theory of interpretation: “First, that interpretation strives to present its object in its best possible light. Second, that interpretation is essentially genre-dependent. And third, that there are certain constraints that determine the limits of possible interpretations of a given object.” Why the best light? Dworkin doesn’t really address this question in depth but claims that otherwise we are left with no way of justifying and choosing an interpretation or we are left with the author’s intention model, which we should reject. [Marmor doesn’t seem clear on what precisely it means to present something in its best light – seems to conflate it with most appealing light which, I take it, is different than what Dworkin has in mind.] “Dworkin is quite right to maintain that without having some views about the values inherent in the genre to which the text is taken to belong, no interpretation can take off the ground. The values we associate with the genre partly, but crucially, determine what would make sense to say about the text, what are the kinds of meaning we could ascribe to it.” There is no necessity for an interpretation to present an object in its best light with regards to the genre it is taken to be part of. Interpretations “could simply strive to present it in a certain light, perhaps better than some, worse than others, but in a way which highlights an aspect of the meaning of the text which may be worth paying attention to for some reason or another.” [What kind of reasons would count in choosing to present it in one light rather than another?] There is simply zero grounds for Dworkin’s assertion that we have no reason to pay attention to an interpretation that does not present it in its best light. Take a psychoanalytic interpretation of Hamlet, for example – not the best light, but a legitimate one. [This seems related to the next criticism – clearly Dworkin would have to loosen his insistence on the best, though not to detriment.] Moreover, especially with regards to art, it doesn’t appear possible to make an all things considered judgment about the best interpretation given the incommensurability of different values that are taken to inhere in a given genre. [Dworkin can respond here that we may have different available interpretations that could be justified with respect to the relevant value. Moreover, a lack of common denominator does not prevent any comparison whatsoever.] Constructive interpretation concerns social practices constituted by norms – it imposes a purpose or value rendering intelligible the normative character of the practice. There is a separate aspect of constructive interpretation that maintains that elements of the practice are sensitive to the point of the practice. It is important to note that different social practices will institutionalize themselves in different ways – thus, different practices will establish varying conditions on how the practice can be altered. The position of the positivists is that evaluative judgments concerning what the law should be are insufficient for determining what the law is given the nature of law’s institutionalization.&nb p; [This would seem to reside on a certain conception of law, i.e. an interpretation about where the value of law lies.] “[T]his being one of the main points of dispute between Dworkin and his positivist opponents, Dworkin cannot at this initial state presume law to be sensitive to its value in the manner that other, non-institutional practices might be, without incurring the charge of having assumed the very point at issue.” The upshot for Dworkin is that any explanation of a social practice such as law requires the same kind of reasoning as participation in that practice. This will be called the hermeneutic thesis. We can try to reconstruct a justification for this view based on the necessity of shared background assumptions – but this will not do since Dworkin’s claim is stronger: it contends that participants’ and theorists’ must “adopt one and the same normative point of view.” [The sense of normative here is unclear. It is true, though, that shared background assumptions do not imply viewing the law as valuable in any particular way, or at least it does not imply this in any strong sense.] Dworkin makes two distinct points with the hermeneutic thesis: “First, that the explanation of a social practice, like law or the arts, is essentially interpretative, and as such, necessarily value laden. Second, that the interpretation of such social practices, which Dworkin calls ‘argumentative’, is unique in the sense that the practice itself is an evaluative enterprise, and that therefore the interpreter of such a practice must form an evaluative judgment of her own about those values which are inherent in the practice that she purports to interpret.” [As stated, the first thesis is terribly ambiguous – for Dworkin, it clear implies a commitment to constructive interpretation. For Marmor, who accepts it, it is totally unclear what commitment he intends to make. He seems to mean simply that we have criteria for success concerning what counts as a successful explanation.] Mamor denies the second thesis. “What Dworkin seems to ignore here is that there is a crucial difference between forming a view about the values which are manifest in a social practice, like law, and actually having evaluative judgments about them.” [The problem, however, it that it is a contentious matter what values are part of the law – a theorist’s account of what values are constitutive of a particular legal system must rely on the kind of arguments which participants rely on. Of course, a theorist might simply note a debate about values and attempt to remain agnostic, but this will fail to be a full theoretical account of what law is!] Dworkin’s thesis seems to depend exclusively on his account of constructive interpretation. [This seems exactly right.] Chapter 4: Coherence, Holism, and Interpretation: The Epistemic Foundation of Dworkin’s Legal Theory Begins with discussion of Rawls’ reflective equilibrium. Sums up dual criticism as follows: “[T]he assumption that intuitions are independently true and the converse one, that their truth depends on fitting a coherent scheme, both seem to yield paradoxical results.” Dworkin, in his article “The Original Position”, claims that Rawls cannot commit himself to ethical realism. “[T]he natural model presupposes some form of ethical realism, while the constructive model does not. One important difficulty arising from an attempt to apply the natural model to Rawls is, that under the natural model, any theory which dopes not account for an intuition, at least for one which is held firmly, cannot be wholly satisfactory, just as scientific theory which does not account for certain observational data it is supposed to cover, would not be satisfactory in a familiar way.” Rawls, rather, is committed to a constructivist view of morality. Moreover, the reason we value coherence epistemically in moral theory is that it itself is a value of political morality – fairness requires consistency and publicity in the application of moral standards. Marmor notes the following problem with such a view: “[I]f coherence is justified, as it is here, with reference to certain moral values, that is, a specific conception of fairness, then we face the following problem: the presupposed values of fairness must themselves be based upon intuitive convictions, in which case the question of their truth cannot be ignored. If they are taken to be true…we are driven back to the perplexities of the natural model.” Discusses, helpfully, the Fish/Dworkin debate. The upshot is that Dworkin’s interpretive model is best off if it commits itself to a Quineian holism. However, this undermines his distinction between internal and external skepticism since holism must deny that moral judgments constitute a closed system. [This analysis seems exactly right.] Endorses Simmonds view that Dworkin’s theory does not meet the requirements of complexity he identifies as necessary to avoid vicious circularity in interpretive judgments of fit and identity. Coherence is doing the work through and through and therefore the interpretive theory of law is circular. [Will require further investigation, though it is unclear how coherence is doing any work in the pre-interpretive stage. At this stage, the judgments, if interpretive, seem to be derived from different sources. In any case, using coherence as a value seems to be highly suspect.] Why doesn’t Dworkin just reject Fish’s assumptions: because of his jurisprudence. “If legal texts can have a meaning that is not entirely dependent on a process of interpretation, then it is at least sometimes the case that the law can simply be understood, and applied, without the mediation of interpretation. And if that is the case, then the argument from interpretation against legal positivism collapses. It is no longer the case that every conclusion about what the law is, depends on evaluative considerations about what it ought to be.” Chapter 5: Semantics, Realism, and Natural Law Assessment of Michael Moore’s legal realism and its implications. [The final criticisms of Moore are not decisive.] Chapter 6: Constructive Identification and Razian Authority A consideration of Dworkin’s denial that the communication model of interpretation is appropriate for legal interpretation. Marmor argues that intentions do play a crucial role in the identification of legal norms in a way that is incompatible with Dworkin’s “coherence thesis”. Marmor takes Dworkin to be committed to the constructive identification thesis: that the identification of something as part of the legal, artistic, etc. genre can be done sufficiently by evaluative considerations. “Here, one must maintain that evaluative considerations are sufficient to determine whether something is a legal norm or a work of art”. [Fit, however, constrains possible evaluative considerations – thus evaluative considerations are not sufficient in themselves.] “Now the crucial point here is this: if you maintain the possibility of constructive identification in art, you must assume that works of art can be identified as such on the basis of certain features they happen to possess, features which contain no reference to any particular intention to create a work of art…unless we take intentions into account, how can we discriminate between the concept of an aesthetic artifact and the con ept of a work of art?” [It is unclear, and I think false, that constructive interpretation of anything requires identifying something irrespective of an artificers intentions. Those intentions may be relevant, dependent upon the genre under which we are trying to classify the object. Nothing, seemingly, about constructive interpretation in general excludes this possibility.] Marmor’s point is that it turns out to be impossible to identify art as art without reference to an artist’s intentions – especially given the state of contemporary art. [It is notable that Marmor’s response to counterexample implicitly depends upon a fully developed theory of aesthetics. His cursory comments on the matter of identifying art seem insufficient to say the least.] The rest of the chapter considers the incompatibility of Raz’s account of authority with constructive interpretation. The incompatibilities mentioned do not move beyond what Raz identifies in his article “Authority, Law and Morality”, but a defense of this notion of authority is defended in several [inconclusive] respects. [Raz and Marmor want to separate identification from content. This is not clearly a defensible separation.] Chapter 7: No Easy Cases? Chapter defends notion that there is a distinction between easy and hard cases in the positivist sense. Takes a Hartian approach and ultimately defends the distinction by associating it Wittgenstein’s conception of rule following. The point is that one need to look the purpose of rule in order to understand what the rule requires. Chapter 8: Legislative Intent and the Authority of Law Examines the following doctrine concerning the role of legislative intent in adjudication: “[F]irst, it would hold that laws, at least in certain cases, are enacted with relatively specific intentions, and that this is a matter of fact which is discernible through an ordinary fact-finding procedure. Second, that in certain cases the presence of such a fact, namely, that the law was enacted with a certain intention, provides judges with a reason to decide the legal dispute in accordance with the relevant legislative intent.” [It is important that for Marmor, interpretive strategies are only appropriate in hard cases. However, we should wonder what grounds positivism can offer for deciding a hard case in any manner which is not the morally best manner according to the judgment of the judge. There are no legal grounds, by definition, in hard cases and so what justificatory strategy would endorse any judicial decision except for the morally best one?] We can ascribe intentions to a legislative body, when this is possible at all, by taking the shared intentions of the majority, rather than some group intention, to be the significant intentions. Moreover, we should expect a good deal of consensus about intentions for otherwise it is hard to explain how legislative bodies are able to produce so much legislation. Discussion of kinds of intentions concludes as follows: “I have distinguished between three main types of intention that are potentially relevant from the legal point of view. Apart from the intentions that are manifest in the language of the law itself, legislators typically have further intentions in enacting a given law, and sometimes they would have certain intentions bearing on its proper application. I have also suggested that some of these further intentions may be essentially non-avowable, in which case they are rendered initially irrelevant. Finally, I have pointed out that considerations of consistency require that the legislator’s application intentions be taken into account only if, and to the extent that, they are in accord with his further intentions.” The manner in which intentionalism is to be justif ed relies on the distinction, Marmor maintains, between expert and mere collective action authority. “The point I wanted to make is strictly conditional: if, and only if, a certain law is justified on the basis of the expertise branch of the normal justification thesis, would it make sense to defer to the legislature’s intentions in the interpretation of the law, that is, to the extent that there is, in fact,; such an intention and it can clarify something that needs clarification.” Insofar as a legislature can be considered an expert on the matter requiring adjudication and interpretation should the body’s intention be taken into account. Chapter 9: Constitutional Interpretation Begins by laying out general necessary features of a constitution. Then Marmor moves on to consider general questions of constitutional legitimacy. First, he considers what grounds might be offered for the legitimacy of a constitution at all. He notes that the central question is what permits a single generation to bind future generations. He then examines four arguments to avoid this problem. The first is based on the moral legitimacy of the constitution; Marmor rejects this solution for the [truly dubious] reason that the constitution would make no practical difference because it would not supply reasons in addition to those provided by morality [but, presumably, the point is that these legally valid rules would be institutionally enshrined]. The second is based on the moral authority of the framers and Marmor rightly rejects this on the basis of the idealization of the framers it requires and less rightly on the basis that there cannot be moral authorities. Third is the “argument from interpretation” which claims that “as long as the particular content of the constitution is determined by its interpretation, and the authoritative interpretation at any time correctly instantiates the values which ought to be upheld in the community, the constitution would be morally legitimate”. The fourth is Raz’s which argues that a constitution is valid so long as its constraints are morally permissible because conventions of this type might aid the continuity of the legal system, i.e. it is important to have a convention of this type and the constitution is a kind of this type. Marmor appears to endorse these two approaches and concludes: “The conditions for the legitimacy of a constitution must comprise the following conditions. First, the values and principles enshrined in it must be morally permissible…Second, when certain choices are made in particular cases, they would be legitimate if they are either morally underdetermined, or else, morally correct…It follows from this that both arguments must assume that at least in those areas in which the constitution would make a moral difference, it can be interpreted to make the difference that it should, that is, according to the true moral principles that should apply to the particular case...the moral legitimacy of constitutions very much dependent on the practices of their interpretation. In other words, a great deal of the burden of moral legitimacy is shifted by these arguments to the application of the constitution, thus assuming that the constitution is legitimate only if the courts are likely to apply the constitution in a morally desirable way.” [This implies that the only significant value constitutions have is in providing a conventional practice where some such practice is required.] Moves on to argue that courts typically rely, and rightly so, on moral considerations when deciding constitutional issues because typically, in cases of the kind that reach the supreme or constitutional court, there is no law on the case. Much of this relies on his earlier discussion about the nature of interpretation in the law – that legal interpretation is always a matter of cha ging the law. (shrink)

It is widely presumed, at least among typical Western physicians and medical lay persons, that the Hippocratic and the Judeo- Christian traditions in medical ethics are closely connected or at least compatible. We examine the historical, metaethical, and normative relationships between them, and we find virtually no evidence of any historical links prior to the ninth century. In fact, important differences between them are found. The Hippocratic Oath appears to reflect the environment of a (...) Greek mystery cult. It includes a commitment to secrecy and a sense of community alien to Judeo- Christian tradition. Differences between the two traditions on the issues of killing and life prolongation, abortion, surgery, and normative ethical principles including truth-telling, autonomy, and justice are also explored. We conclude that important differences not only exist but also raise serious problems for persons identifying with both traditions. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Bad, the Ugly, and the Need for a Position by PsychiatryLloyd A. Wells (bio)Keywordsvice, psychiatric education, psychiatry-law interface, medicalizationSadler’s paper is thought provoking and will resonate with many psychiatrists who deal with the interface of vice and psychiatric syndromes. This interface and the dilemmas it poses are perhaps most discussed by residents, who are dealing with the issue for the first time and who often debate what is (...) “psychiatric” about these cases. Many residents have their own informal systems of classifying vice, often with a divide between the criminal population and those perceived as avoiding work and responsibility. These unofficial classifications are usually judgmental and often pejorative, but the residents rarely get much help from faculty in this area. Indeed, many of the faculty have equally judgmental and pejorative views, which are neither systematized nor subject to systematic analysis.By clarifying the importance of the issue of the vice–mental disorder relationship (VMDR) to psychiatry, Sadler may move this topic to one that receives Socratic discourse in our training programs and serious consideration in the training of psychiatrists rather than an idiosyncratic lumping of these patients into the broad category of “patients I don’t like.”Sadler asks for comments in several categories: historical intractability, goals of psychiatry, taxonomy, implications for the criminal justice system, implications for the law, and ethical/political implications.Issues of historical intractability are long standing. In A Tour of the Whole Island of Great Britain, written in the early eighteenth century, Daniel Defoe (1724–1727) describes many asylums, often with the comment, “as it is a madhouse, so is it also a house of correction.” Some of the great public hospitals of the seventeenth and eighteenth centuries were built at least as much to get antisocial and homeless people off the streets as to provide care for the mentally ill. The moral treatment of France and Great Britain, which added much to the practice of psychiatry, clearly had punitive “treatments” for patients with vice-laden behaviors, and this was very explicit in the American moral model of treatment of the late nineteenth century with its obsessive need to prevent patients from masturbating. In the nineteenth and early twentieth centuries, there was great debate about the inclusion of Pritchard’s “moral insanity”—now sanitized into “personality disorders”—into the psychiatric domain, and Kraepelin referred to this group as “enemies of society.”Sadler next asks us to consider the goals of psychiatry in regard to “a proper VMDR.” He wonders [End Page 43] whether a strict medicalization account can be defended. I think it is clear from a large literature and from clinical experience that it cannot be defended —now. But it may become defensible in this century, which will pose enormous challenges to psychiatry, lawmakers, and the courts (vide infra). A strict moralization model is defended by many in society, including some psychiatrists, but has severe limitations and seems illogical. It is hard to make a case (though juries have done so) that, for example, a very delusional young woman with postpartum psychosis who murders her children because of the belief that far worse things than death will happen to them imminently if they live, fits the moralization approach. The Dahmer case is especially instructive. Although there was enormous “vice” (and perhaps “evil”), it is hard to make a case that a sane man would make temples out of the body parts of victims and would attempt to commune with the dead through them.He wonders whether a “mixed” version of medicalization/moralization can be developed and defended. I would argue for both a mixed approach and a “shared” approach. A middle adolescent with bipolar disorder burned his house to the ground. (Fortunately, he and family members were injured but not killed.) He was wildly manic at the time and set the fire because he wanted to prove that he was immortal and totally impervious to flames. He was delusional, extraordinarily impulsive, and completely without judgment, and it would be extraordinarily difficult to exclude the medical frame in any consideration of the vice involved. The vice, indeed, may be more involved in his decision while euthymic to stop taking... (shrink)

The predominant position in the reproductive rights literature argues that access to assisted reproductive technologies (ART) forms part of an individual’s right to reproduce. On this reasoning, refusal of treatment by clinicians (via provision) violates a hopeful parent’s reproductive right and discriminates against the infertile. I reject these views and suggest they wrongly contort what reproductive freedom entitles individuals to do and demand of others. I suggest these views find their origin, at least in part, in the (...) way we define “reproduction” itself. This paper critically analyses two widely accepted definitions of human reproduction and demonstrates that both are fundamentally flawed. While the process of reproduction includes the biological acts of begetting and bearing a child, I argue that it does not extend to include rearing. This reworked definition has little impact in the realm of sexual reproduction. However, it has significant ethical implications for the formulation and assignment of reproductive rights and responsibilities in the non-sexual realm in two important ways. First, a claim to access ART where one has an intention to rear a child (but does not beget or bear) cannot be grounded in reproductive rights. Second, lacking an intention to rear does not extinguish the reproductive rights and responsibilities for those who collaborate in the process. I conclude that clinicians collaborate in non-sexual reproduction at the point of triggering conception (begetting) and therefore have the right to refuse to be involved in non-sexual reproduction, in some instances, as do all reproductive collaborators. (shrink)

It probably should not be surprising, in this time of soaring medical costs and proliferating technology, that an intense debate has arisen over the concept of medical futility. Should doctors be doing all the things they are doing? In particular, should they be attempting treatments that have little likelihood of achieving the goals of medicine? What are the goals of medicine? Can we agree when medical treatment fails to achieve such goals? What should the physician do and (...) not do under such circumstances? Exploring these issues has forced us to revisit the doctor-patient relationship and the relationship of the medical profession to society in a most fundamental way. Medical futility has both a quantitative and qualitative component. I maintain that medical futility is the unacceptable likelihood of achieving an effect that the patient has the capacity to appreciate as a benefit. Both emphasized terms are important. A patient is neither a collection of organs nor merely an individual with desires. Rather, a patient (from the word to suffer ) is a person who seeks the healing (meaning to make whole ) powers of the physician. The relationship between the two is central to the healing process and the goals of medicine. Medicine today has the capacity to achieve a multitude of effects, raising and lowering blood pressure, speeding, slowing, and even removing and replacing the heart, to name but a minuscule few. But none of these effects is a benefit unless the patient has at the very least the capacity to appreciate it. Sadly, in the futility debate wherein some critics have failed or refused to define medical futility an important area of medicine has in large part been neglected, not only in treatment decisions at the bedside, but in public discussions—comfort care—the physician’s obligation to alleviate suffering, enhance well being and support the dignity of the patient in the last few days of life. (shrink)

Ethical challenges surrounding the implementation of male circumcision as an HIV prevention strategyResearchers have been exploring the possibility of a correlation between male circumcision and lowered risk of HIV infection almost since the beginning of the HIV/AIDS epidemic.1 Results from a randomised controlled trial in South Africa in 2005 indicate that male circumcision protects men against the acquisition of HIV through heterosexual intercourse,2 confirming the findings from 20 years of observational studies.3 Circumcised men in the South African trial were 60% (...) less likely to acquire HIV than their uncircumcised counterparts. A mathematical modelling study, based on the South African trial, estimates that the practice of male circumcision could avert two million new HIV infections and 300 000 HIV-related deaths over the next 10 years in sub-Saharan Africa.4 More recently, two randomised controlled trials in Kisumu, Kenya and Rakai, Uganda showed, respectively, 53% and 48% reductions in HIV acquisition among circumcised men than uncircumcised men in the trial.5 These results strongly suggest that male circumcision could play an important role in the struggle against the continued rise in new HIV infections. However, as observers noted at the 2006 XVI International AIDS Conference in Toronto, Canada, excitement about the potential epidemiological impact has overshadowed the debate over the difficult translation of research on male circumcision, into policy and practice.6 Similar calls for caution have been raised before and elsewhere.7,8The topic of male circumcision carries an enormous amount of ethical baggage. Male infants, worldwide, are circumcised for various medical, social and/or religious reasons. Circumcision is a cultural act and a surgical procedure; medical reasons are not the only reasons to circumcise that people have found and continue to find as compelling. Benatar and Benatar9 have argued that—when …. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Clinical Ethics Consult: Transforming Ambivalence to ActionEve MakoffAs palliative care practitioners, we’re good at diffusing explosive family dynamics and holding space for patients and families in emotional crises. We also help everyone involved with the care of seriously ill patients focus on what is best based on the values of the most important person in the room; the one in the hospital bed. So, when we (...) call for a bioethics consultation from a clinical ethicist, it’s because something has gotten stuck or, perhaps, we could benefit from a reframe—or a new set of eyes to ground the scenario or the emotional miasma that tends to linger and drift when on the cusp between life and death.In the 1990s, at least in my medical school and residency programs, medical ethicists in the hospital were not often a part of direct patient care. They were like philosophers, available to curbside and advise on ethically murky cases but at a distance from the trenches. These wise, generally older men with white beards parceled out all potential ethical sides of the case, leaving us to decide the best way forward. The Socratic Method1 was often employed, so we were left to grapple with the ambiguity that exists in most issues about what’s right or wrong. It sometimes felt frustrating but now I realize the importance of honing the skill of tolerating the feeling of not immediately knowing the best way to proceed in the practice of medicine. As it turned out, by the time I started practicing palliative care in 2013 and began to regularly collaborate with what was then our clinical ethics partners in care, our ethics director Dr. F was also a wise older man with a white beard. But he and the rest of his (non-male, un-bearded) team didn’t have that untouchable ivory tower kind of protection around them. They were accessible. They dug into the hard stuff right alongside us when they were asked to get involved.One time when I consulted ethics on a case, I’d been navigating a switch from practicing internal medicine to palliative care. At the time I was dealing with personal ambivalence—feeling mired in the heaviness that infused my workdays and unsure if I could take it. It turned out that a clinical consultation, and a family meeting with Dr. F, helped in more ways than one.That day, we gathered in the medical intensive care unit conference room. It doubled as a storage closet, so the team, including our patient’s family, dragged in chairs and stools and crowded around the oblong melamine table next to the whiteboard with half-erased arterial blood gas calculations. We hunched together to see where things stood and make some essential decisions.As we do in family meetings, we reconfirmed our roles on the team: ICU fellow, resident, and medical student. Nurses fluttered in and out as their patient care allowed. The patient’s daughter with silver-streaked hair was in attendance, as well as her son, who was slumped in his seat. Both looked sleepless and frazzled. And finally, Dr. F and myself—clinical ethicist and palliative care doctor—gathered. Dr. F then took the lead, announcing our intention to come together and discuss what was best for our patient—their mother. Dr. F then requested a medical update from the ICU team.“Mrs. Lyons is on a ventilator. She’s sedated and medicated for pain. But her organs aren’t doing well. She’s not getting better,” the resident read off of his white paper of scribbles. [End Page 12]Suspended between her life and her death, Mrs. Lyons lay unperturbed but unreachable, and her family was agonizing about what to do. For days our palliative team had discussed the options with the family—we could cut back on the medications and try to wake her up, knowing she’d likely have considerable pain, and to what end? We could reconsider that surgery for her infected bowels, but she’d likely not survive.Or we could let her go—discontinue the ventilator and likely let her die.They could not decide... (shrink)

Research ethics is a very exciting field at the moment. Important public debate is continuing at national and international levels, concerning the proposed revisions to the Declaration of Helsinki and the Council for the International Organisation of Medical Sciences (CIOMS) guidelines, the proposed European clinical trials directive and the recent Good Clinical Practice guidelines. There is also debate about obtaining, using and storing genetic, and tissue, samples. This ferment has resulted in a wealth of guidelines and learned (...) articles, but as yet there are few useful and up-to-date book-length discussions of the field. This is partly due to the increasing diversity of types of research (including research design), and the variety of the contexts of research (the hospital-based clinical trial is arguably no longer typical of medical research). However, it is also to do with what such a book is supposed to do. Recent works like Baruch Brody's Ethics of Biomedical Research (OUP, 1998) give, in effect, an …. (shrink)

Medical ethics enjoyed a remarkable degree of continuity from the days of Hippocrates until its long-standing traditions began to be supplanted, or at least supplemented, around the middle of the twentieth century. Scientific, technological, and social developments during that time produced rapid changes in the biological sciences and in health care. These developments challenged many prevalent conceptions of the moral obligations of health professionals and society in meeting the needs of the sick and injured .The Anglo-American textbook (...) of Beauchamp and Childress became the referential work for the discipline of `bio-ethics'. The authors are convinced that a long history of ancient, medieval and modern health care reflection remains very disappointing from the perspective of contemporary biomedical ethics: “It shows how inadequately, and with what measure of insularity, problems of truthfulness, privacy, justice, communal responsibility and the like were framed in past centuries ”. They defend the four principles approach to biomedical ethics, an approach which somewhat disparagingly has been called principlism.The influence of their work has been so strong that bio-ethics seemed to become overwhelmed by the importance of their contribution. It even created a large separation between Anglo-American approaches in bio-ethics and the European-Continental approach . In any case, contemporary biomedical ethics incorporates theoretical conflicts of considerable complexity, and the diverse theories make it no easier.The personalist approach to biomedical ethics presents itself as a typical European reaction to the rapid changes in medicine and health care. Some call it, however, a kind of renewal of the old Thomistic approach, whereby the concept of `nature' has been replaced by the more dynamic concept of `person'. In that way personalism has been situated by many observers as a `person' centred natural law tradition which focuses on the rational nature of the human person as the moral norm of nature. This gives the impression that personalism is only a very `static' variant of the natural law approach.I would, however, defend the opinion that personalism offers a very dynamic and creative approach to the complexities of recent developments in biomedicine. In what follows, I will illustrate this by clarifying two basic dimensions of the integration of personalism in biomedical ethics: the personalist approach offers a relational foundation for medicine as a healing profession and it presents an ethical framework for the integration of new developments in medicine. First, however, I would like to situate the importance of this theoretical reflection for medical ethics. (shrink)

We examined nurses’ perceptions of the ethical climate of their workplace and the relationships among the perceptions, medical error experience and intent to leave through a cross-sectional survey of 1826 nurses in 33 Korean public hospitals. Ethical climate was measured using the Hospital Ethical Climate Survey. Although the sampled nurses perceived their workplace ethical climate positively, 19% reported making at least one medical error during the previous year, and 25% intended to leave their jobs in the near (...) future. Controlling for individual and organizational characteristics, we found that nurses with a more positive perception of the ‘patient’ dimension of ethical climate were less likely to have made medical errors. Nurses with a more positive perception of the ‘patient’, ‘manager’, ‘hospital’ and ‘physician’ dimensions of ethical climate were less likely to leave their current job. Enhancing workplace ethical climate could reduce medical errors and improve nurses’ retention in public hospitals. (shrink)

BackgroundBioethics can play an important role in addressing diversity both in and outside of academia, setting precedents for meaningful contributions to public discourse, research, teaching, training, and policy development. However, in order to do so, these conversations also need to reflect on the issue of diversity within the field of bioethics across the globe. This study aims to examine current gender representation and diversity at medical ethics and humanities institutes in Germany, the German-speaking areas of Switzerland, and (...) Austria.MethodsA total of forty-nine medical ethics and humanities institutes from Germany (n=42), the German-speaking areas of Switzerland (n=5), and Austria (n=2) were included in the study. Institutes websites were reviewed in the first week of March 2021 and the details of each staff member listed on the website recorded.ResultsOverall, a total of 964 staff members were identified at the forty-nine German-speaking medical ethics and humanities institutes. Just over half (530/964; 55%) of all staff were female. There were significant differences between gender in some staff positions: 64.6 per cent (31/48) of directors were male (χ2(1)=4.1, P=.04); 62.7 per cent (84/134) of student assistants were female (χ2(1)=8.6, P=.003); and 83.7 per cent (77/92) of administrative staff were female (χ2(1)=41.8, P<.001). There were no significant differences between staff gender for researchers and lecturers, or associated researchers. In addition, 65.5 per cent (19/29) of researchers and lecturers who had a professor title were male, but the difference between genders was not found to be significant. However, significantly more of the researchers and lecturers who had completed a habilitation were male (75.8% (25/33); χ2(1)=8.8, P=.003). When comparing the institute director’s gender presentation with staff gender presentation, it was found that male-led institutes had 53.4 per cent (286/536) female staff overall but had 52.7 per cent (136/258) male researchers and lecturers. However, the difference between genders were not found to be significant. On the other hand, female-led institutes had significantly more female staff overall (59.9% (223/372); χ2(1)=14.7, P<.001) and also significantly more female researchers and lecturers (58.9% (119/202; χ2(1)=6.4, P=.01).ConclusionsThere has been a significant push to address gender diversity in German-speaking academia, and this study finds overall good gender parity in medical ethics and humanities institutes. However, there has not been a similar openness to discussing issues of systemic racism or how other forms of inequality affect academic diversity. Taking diversity seriously requires opening up conversations around intersectionality, including difficult conversations around race and cultural background that have long been taboo in German-speaking countries. (shrink)

The issues of medical ethics, from moral quandaries of euthanasia and the morality of killing to political dilemmas like fair healthcare distribution, are rarely out of today's media. This area of ethics covers a wide range of issues, from mental health to reproductive medicine, as well as including management issues such as resource allocation, and has proven to hold enduring interest for the general public as well as the medical practitioner. This Very Short Introduction provides an (...) invaluable tool with which to think about the ethical values that lie at the heart of medicine. This new edition explores the ethical reasoning we can use to approach medical ethics, introducing the most important 'tools' of ethical reasoning, and discussing how argument, thought experiments, and intuition can be combined in the consideration of medical ethics. Considering its practical application, Tony Hope and Michael Dunn explore how medical ethics supports health professionals through the growing use of ethics expertise in clinical settings. They also contemplate the increasingly important place of medical ethics in the wider social context, particularly in this age of globalization, not only in healthcare practice, but also policy, discussions in the media, pressure group and activism settings, and in legal judgments. ABOUT THE SERIES: The Very Short Introductions series from Oxford University Press contains hundreds of titles in almost every subject area. These pocket-sized books are the perfect way to get ahead in a new subject quickly. Our expert authors combine facts, analysis, perspective, new ideas, and enthusiasm to make interesting and challenging topics highly readable. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Bioethics in the Twenty-First Century: Why We Should Pay Attention to Eighteenth-Century Medical EthicsLaurence B. McCullough (bio)Those of us who work in the field of bioethics tend to think that, because the word “bioethics” is new, so too the field is new in all respects, but we are not the first to do bioethics. John Gregory (1724–1773) did bioethics just as we do it, at least two (...) centuries before we thought to do it (Gregory 1772). He deployed philosophical methods as sophisticated as our own. Indeed, Gregory took up the very best moral philosophy available to thinkers of the Scottish Enlightenment, namely, David Hume’s moral philosophy and its core concept of sympathy. Gregory also responded in a conceptually powerful and clinically applicable way to the problems of his time, just as we do. I want here to outline Gregory’s accomplishment and to identify some aspects of its importance for bioethics in the twenty-first century.Gregory’s “Problem List”Gregory wrote his medical ethics as a response to the then current state of medicine in Britain. We now follow Gregory in our writing of bioethics and clinical ethics in response to the problems of our time. A great deal that we now take for granted did not then exist. 1There was not, as there is now, any uniform pathway into medicine. Nor did there exist universal licensure. The Royal Colleges did attempt to assert, but failed to achieve, monopoly control of medical practice. The concepts of health and disease were themselves contested and therefore competed for their success in the market place. There was a marked oversupply of practitioners who competed fiercely—very fiercely indeed—in the medical market place for their concepts of health and disease, their treatments, and therefore their livelihoods. Patients had their own concepts of health and disease, engaged in “self-physicking” or self-care, and often traded physician’s prescriptions.Medicine exhibited little scientific discipline in its accounts of disease and in determining the efficacy of treatments, a fact that Gregory (1743) laments as a [End Page 329] medical student. There was no marked improvement when he began to give his medical ethics lectures nearly a quarter of a century later. Treatments failed as often, perhaps more often, than they succeeded in benefiting patients. The sick usually sought out the help of a physician after trying self-physicking.Physicians, Gregory taught, could not hope to control human biology, though they could aim to manage its processes well. When nature underresponds to disease the physician should assist her processes; when nature overresponds, the physician should tamp down nature’s responses, to lessen their “violence”—in both cases always attentive to the limits of medicine’s capacities in treating disease.Physicians attended the well-to-do sick at home, and the sick person summoned and dismissed physicians, surgeons, or apothecaries at will. A physician therefore might find himself—no women had yet been admitted to the ranks of university-trained physicians—summoned before, after, or simultaneously with a competitor, with his concepts and diagnosis and treatment put to the acid test. In this setting, there existed only a patient-physician relationship, not a physician-patient relationship.Physicians left off the care of dying patients, a practice that was made a matter of duty by Friederich Hoffmann (1749). One would suffer punishing economic consequences if one had a high mortality rate. Better, then, to label the patient incurable, withdraw, and turn matters over to clergy. Gregory attacks this practice as intellectual fraud and calls for the physician to continue to attend the dying. Indeed, he says, “It is as much the business of a physician to alleviate pain, and to smooth the avenues of death, when unavoidable, as to cure diseases” (Gregory 1772, p. 35). He does not explicitly address what we now call physician-assisted suicide; neither does he condemn it, and he is quick to condemn some things—e.g., sexual abuse of female patients or “sporting” with patients in the Royal Infirmary by using experiments as the first line of treatment.The Royal Infirmary was established to care for the deserving, working poor, who received free care... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:A Report from the Front Lines: Conversations on Public Theology. A Festschrift in Honor of Robert Benne, and: Explorations in Christian Theology and Ethics: Essays in Conversation with Paul L. LehmannJeffrey P. GreenmanA Report from the Front Lines: Conversations on Public Theology. A Festschrift in Honor of Robert Benne Edited by Michael Shahan Grand Rapids, Mich.: Eerdmans, 2009. 184 pp. $30.00.Explorations in Christian Theology and Ethics: (...) Essays in Conversation with Paul L. Lehmann Edited by Philip G. Ziegler and Michelle J. Bartel Farnham, Surrey, UK: Ashgate, 2009. 206 pp. $99.95.The volumes reviewed here each recognize an important thinker in Christian social ethics in America: Robert Benne, emeritus professor of religion at Roanoke College, a Lutheran social ethicist; and Paul L. Lehmann (1906–94), a Presbyterian who was an influential teacher associated with Princeton Theological Seminary, Harvard University Divinity School, and Union Theological Seminary in New York.The first volume honors Benne’s seventieth birthday. His major writings include The Ethic of Democratic Capitalism: A Moral Reassessment (1981), Ordinary Saints: An Introduction to the Christian Life (1988), The Paradoxical Vision: A Public Theology for the Twenty-First Century (1995), Quality with Soul: How Six Premier Colleges and Universities Keep Faith with Their Religious Traditions (2001), and most recently, Good and Bad Ways to Think about Religion and Politics (2010). Since Benne is known for his traditionalist moral views, some unmistakably conservative voices, including a number of prominent Lutherans and neoconservative political thinkers, are represented in this book. The broad theme is public theology, working from Benne’s definition of public theology as “the engagement of a living religious tradition with its public environment—the economic, political, and cultural spheres of our common life.”The book has three parts. The first section, “The Imperative of a Public Theology,” includes essays by editor Michael Shahan, Carl Braaten, Jean Bethke Elshtain, and Richard John Neuhaus. Shahan’s essay provides a helpful exposition of Benne’s intellectual trajectory. Braaten offers a defense of the historic, bodily resurrection of Jesus as the “crux of Christianity’s case.” Elshtain takes [End Page 206] up C. S. Lewis’s concerns in his Abolition of Man (1944) as she diagnoses the “cultural disorder” reflected in current debates about euthanasia and abortion. Neuhaus’s wistful essay looks back over his efforts in the public square, stating that he and Benne have shared a common concern: “A renewal of Christian confidence in providing a morally informed philosophy for a more just and virtuous society in the tradition of liberal democracy” (47). Taken together, these four chapters sketch the assumed intellectual and cultural landscape that sets the context for the volume as a whole.The second section, “The Lutheran Necessity in Public Theology,” begins with a largely autobiographical essay by James Nuechterlein about his journey in Lutheranism and the value of its theological distinctives, especially the famous simul. Next is Gilbert Meilaender’s account (exploring an insight from Kierkegaard) of the place for a Lutheran “corrective” within the wider normative tradition, then Mark Noll’s chapter that underscores the value of robust Lutheran social thinking against the backdrop of the more revivalist and pietist tendencies of Protestant evangelicalism.The final section, “Contested Issues in Public Theology,” includes chapters by Paul Hinlicky, Ronald Thiemann, Gerald McDermott, Donald Schmeltekopf and Michael Beaty, and Joseph Swanson. The chapters by Hinlicky on Luther’s relation to liberal political theory, and by Thiemann on the idea of the public theologian’s prophetic role as “connected critic,” are the most densely argued material in the book. These two essays will probably be of the most interest for scholars in theological ethics. The chapter by McDermott deals with Lutheran church-related colleges. A coauthored essay by Schmeltekopf and Beaty champions the vocation of Christian university education. Swanson situates Benne’s economic writings within neo-conservative thought.The book takes up some of Benne’s favorite themes and interest areas, but only rarely do the authors engage Benne’s own thought. Virtually nowhere do they prod Benne to become clearer, to strengthen his arguments, or to modify his conclusions. I would have preferred a deeper engagement with Benne’s ideas; in several... (shrink)

One of the societal problems in a new influenza pandemic will be how to use the scarce medical resources that are available for prevention and treatment, and what medical, epidemiological and ethical justifications can be given for the choices that have to be made. Many things may become scarce: personal protective equipment, antiviral drugs, hospital beds, mechanical ventilation, vaccination, etc. In this paper I discuss two general ethical principles for priority setting (utility and equity) and explain how these (...) principles will often point in diverging directions. Moreover, each of these principles can be understood in different, again often competing, ways. Notwithstanding these controversies and conflicts, in the context of pandemic response there are at least some points of convergence: several policies can be justified by appeal to different ethical principles and theories. Convergence may be found with respect to a focus on saving the most lives (instead of other aggregative accounts); giving priority antiviral prophylaxis and therapy for life-saving pandemic responders; and, partly depending on epidemiology of the pandemic, to prioritise vaccination of children. Although decision-making about access to intensive care will involve choices with immediate tragic implications, the ethical complexity of these choices is relatively modest (although decisions will not be easy): there are persuasive moral reasons for giving priority to patients who are expected to benefit most within the shortest time. Finally, in the last section I tentatively argue that constraints on people’s freedom, as necessary for an effective public health approach, may support giving somewhat more weight to saving the most lives, than to concerns of equity. (shrink)

Because the WMA’s new manual contains a partially partisan view of what constitutes medical ethics, if used for teaching it needs to be balanced by other materialsThe recent publication of the World Medical Association’s Medical Ethics Manual should be welcomed since it gives people all over the world, or at least those people who are on the internet and who have a reasonable printer, access to an introduction to medical ethics that can (...) be used as the basis for an introductory course in medical ethics or for self study.1 The manual covers a wide range of ethical issues in medicine, but much of the focus is on the interaction between the physician and other individual agents—for example, patients and other healthcare professionals.Although there is much that is uncontroversial in the manual, there are a number of places where it is either vague or straightforwardly tendentious. In my short review I will focus on some of these problematic sections.One problem in reviewing this publication is that it is not quite clear to what degree it reflects the views of the WMA. On page two we find the following disclaimer:"This Manual is a publication of the Ethics Unit of the World Medical Association. It was written by John R Williams, Director of Ethics, WMA. Its contents do not necessarily reflect the policies of the WMA, except where this is clearly and explicitly indicated ."In the foreword by the WMA Secretary General, however, we read that the manual is the result of:"… a process [that] was started to develop a basic teaching aid on medical ethics for all medical students and physicians that would be based on WMA policies, but not be a policy document itself ."I …. (shrink)

Chinese medicine has a history of at least 2,000 years. The first explicit literature on medical ethics did not appear until the seventh century when a physician named Sun Simiao wrote a famous treatise titled “On the Absolute Sincerity of Great Physicians” in his work The Important Prescriptions Worth a Thousand Pieces of Gold. In this treatise, later called The Chinese Hippocratic Oath, Sun Simiao required the physician to develop first a sense of compassion and piety, (...) and then to make a commitment to try to save every living creature, to treat every patient on equal grounds, and to avoid seeking wealth because of his expertise. (shrink)

The standard argument in favor of the practice of voluntary physician-assisted death, by means of assisted suicide or active euthanasia, rests on liberal, individualistic grounds. It appeals to two moral considerations: (1) personal self-determination—the right to choose the circumstances and timing of death with medical assistance; and (2) individual well-being—relief of intolerable suffering in the face of terminal or incurable, severely debilitating illness. One of the strongest challenges to this argument has been advanced by Daniel Callahan. Callahan has vigorously (...) attacked the practice of physician-assisted death and the goal of legalization as deep affronts to values of community: “By assuming that the relief of suffering is a goal important enough to legitimate killing as a way of achieving it, we corrupt the idea of such relief as a social goal and duty. We cease helping to bear one another's suffering, but eliminate altogether the person who suffers. We thereby jeopardize both the future of self-determination and the kind of community that furthers its members' capacity to bear one another's suffering. Why bear what can be eliminated altogether?” In another passage Callahan remarks, “For there is a deep sense in which suicide and euthanasia are likely to represent, at least in part, a failure of the community, whether that of the intimate community of family and friends, or the larger civic community, to respond to the needs of another.”. (shrink)

ContentTruth-telling is an integral part of medical practice in many parts of the world. However, recent public inquiries, including the Francis Inquiry reveal that a duty of candour in practise, are at times compromised. Consequently, the duty of candour became a statutory requirement in England. This study aimed to explore clinicians’ perspectives of the implications of the legislation for medical ethics education, as raising standards to improve patient safety remains an international concern.MethodsOne-to-one interviews with clinical educators (...) from various specialties who contribute to the MBChB programme at the authors’ university. Once data saturation had been assessed, transcripts were analysed using a thematic approach by the following concurrent activities: data reduction and coding into themes. Example quotations are used to illustrate that key themes are grounded in the data.ResultsEleven clinical educators were interviewed; three general practitioners, six physicians and two surgeons. Thematic... (shrink)