In pluralist societies, stakeholders in healthcare may have different experiences of and moral perspectives on health, well-being, and good care. Increasing cultural, religious, sexual, and gender diversity among both patients and healthcare professionals requires healthcare organizations to address these differences. Addressing diversity, however, comes with inherent moral challenges; for example, regarding how to deal with healthcare disparities between minoritized and majoritized patients or how to accommodate different healthcare needs and values. Diversity statements are an important (...) strategy for healthcare organizations to define their normative ideas with respect to diversity and to establish a point of departure for concrete diversity approaches. We argue that healthcare organizations ought to develop diversity statements in a participatory and inclusive way in order to promote social justice. Furthermore, we maintain that clinical ethicists can support healthcare organizations in developing diversity statements in a more participatory way by fostering reflective dialogues through clinical ethics support. We will use a case example from our own practice to explore what such a developmental process may look like. We will critically reflect on the procedural strengths and challenges as well as on the role of the clinical ethicist in this example. (shrink)

This study examines Wal-Mart representatives' presentation to the community on their site plan and Draft Environmental Impact Statement. Given the ongoing controversy and criticisms from local residents, it is interesting to see Wal-Mart's strategies in attenuating these risks and negative impacts. The discursive practices found here are: formulating prior citizen complaints by a neutral-sounding, legalistic language which works euphemistically or as a gloss. Citizen concerns are fitted into a problem-solution format where the solutions involve engineering technology. The (...) Wal-Mart representatives display their expertise through describing these technological answers. Scientific documents or tests are presented which point to counter-intuitive results. They draw on a discourse of `facts' and `information', but use these to make arguments in support of their proposals. In addition to displaying scientific-technological expertise, they avow openness to dialogue and willingness to work with the town. The Wal-Mart representatives present themselves as both technical experts and trustworthy partners, but they also may be seen as rhetor in using facts, findings, and documents to make an argument for their project. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:BOOK REVIEWS 375 7he Westminster Dictionary of Christian Ethics. Edited by JAMES F. CHILDRESS and J mrn MACQUARRIE. Philadelphia: The Westminster Press, 1986. Pp. xvii + 678. $29.95. This is a second, revised edition of The Dictionary of Christian Ethics, prepared by John Macquarrie and published in 1967. This new edition follows Macquarrie's conception of a dictionary, but expands it. It includes several subject areas, basic ethical concepts, biblical (...) ethics, theological ethics, philosophical ethics, non-Cbistian ethics; psychological, 8ociological, political, and other relevant concepts; and articles on substantial issues such as war and abortion. The criterion for selection, as stated by the editor, was the importance of the topic for Christian ethical reflection. The aim was to indicate both what is agr.eed upon and what is controversial. About 40% of the entries from the first edition have been included. These are generally updated so as to include recent developments. The selection of subjects, the way in which they are treated and the list of contributors, reflect the ecumenical character of contemporary Christian ethics. The dictionary includes a host of valuable contributions. Readers who consults the work will no doubt evaluate the entries in terms of their particular purposes. This reviewer found most useful the entries which expla~ned particular basic concepts, for example Autonomy; those dealing with schools of thought, for example, Platonic Ethics, Marxist Ethics, or the contribution of particular traditions, for example, Jewish Ethics, Puritan Ethics, Official Roman Catholic Social Teaching, Eastern Orthodox Christian Ethics, and the many entries dealing with Biomedical Ethics and peace issues. 'rhere are a number of articles on topics which are most important, but for which it is often difficult to find a succinct and comprehensive treatment; such are the contributions on "Embodiment," and " Feminist Ethics." There are a number of useful entries on urg.ent contemporary questions such as Energy and Environmental Ethics. Practical questions such as the care of the aged and the ethics of counseling are also addressed. Each article has a short bibliography appended. Numerous cross-references to other relevant entries are most helpful in providing complementary information. There is a thorough index of names. The dictionary is not conceived as a compendium of the accepted or " official " ethical teachings of churches or religious traditions. Mention could be made, however, of the entry on " Official Roman Catholic Social Teaching." '¥here such teachings exist, they am usually indicated. There are some cases where the churches and/or traditions clearly differ. The approach which is most helpful to ethical debate is to acknowledge such differences clearly, with an appropriate statement of the relevant teaching. The editor himself (James F. Childress), in his own contributions, fol- 376 BOOK REVIEWS lows this p1'0cedure. Some Roman Catholic readers may find the articles on Abortion and Contraception, while excellent in other ways, less satisfactory in this respect. The general focus seems intended to be " middle of the road "; more conservative or radical groups may find their views insufficiently represented. No doubt some of the positions presented would be disputed by Christian ethicists. But the treatment of difficult points is balanced and fair. There are, unfortunately, some inaccuracies. The following examples deserve mention. In the article on Nullity, the Roman Catholic annulment is wrongly equated with papal dissolution of the marriage bond. In the article on Virtue, it is said that St. Thomas held that along with the infused supernatural virtues there are "infused natural virtues." St. Thomas spoke ratht>r of infused theological virtues and infused moral virtues (I. II, Q.63, 3.) In the article on deterrence, it is stated that the strategy of "mutual assured destruction ", dating from the 1960s, still provides the framework of American deterrence strategy. This point would be challenged by some representat.ives of the military, who claim that M.A.D. has not been policy for some years. The same article interprets the U.S. Bishops' Pastoral Letter, The Challenge of Peace. as basing its (conditional) acceptance of nuclear deterrence on the distinction between threatening to do an immoral aet without intending to do it, and threat coupled with the intent. That is, deterrence is aceepted as a "bluff." This is not a correct reading... (shrink)

The purpose of this article is to clarify both the role of nurses in ethics meetings and the way in which ethics meetings can function as a catalyst for good nursing care. The thoughts presented are practice based; they arose from our practical experiences as nurses and ethicists with ethics meetings in health care organizations in Belgium. Our reflections are written from the perspective of the nurse in the field who is participating in (inter)professional ethical dialogue. First, (...) the difficulties that nurses experience while participating in ethics meetings are described. Then the possibilities for support of nurses in their ethical responsibility are explored. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Alzheimer's Disease, Aging, Chance, and RaceAtwood D. Gaines (bio)KeywordsAlzheimer’s disease, chance, mild cognitive impairment, racism, social constructionsThomas Kirkwood's comments are a welcome, articulate detailing of how and why we age with special reference to the brain. As well, his paper indicates clearly that processes reified as pathology and disease, such as Alzheimer's disease (AD), are in fact common and inevitable as the human brain ages. Doubtless, this is the (...) reason that aging is by far the greatest risk factor for the development of AD. A key notion, briefly mentioned by Kirkwood, is that of chance. He points out that, "cells (will be) burdened with protein aggregates and similar materials that will increase with aging. Once again, which cells will experience this fate and which will continue to function healthily is strongly influenced by chance" (Kirkwood 2006, 80–81). This mention of chance is most important for our paper, "Building a Mystery," and for an understanding of science as well. In "Building a Mystery," Peter Whitehouse and I sought to show that the history of AD was not inevitable and demonstrates a variety of chance and singular decisive occurrences of encounters, interpretations, social movements, government initiatives, and technological developments. Such decisive moments do not occur by virtue of some (natural) lawful process that is unfolding, but rather, these are chance events that could have happened in other ways. Indeed, science has been viewed as human attempts to "tame chance" (Hacking 1990). However, it often does so by sleight of hand, misinterpretation, and the biomedical discourse of hope. Increasingly, we are learning that chance is a commonality, not a rarity, in social and biological domains. The biomedical approach assumes the opposite. For example, it seeks to tame the chance appearance of AD in the case of Auguste D, and does so in part by reifying differences that exist, as Kirkwood notes, along a continuum rather than as the discrete entities implied by the labels Alzheimer's disease or mild cognitive impairment (MCI).We thus stand with Kirkwood's bold recognition of chance (see also Kirkwood 2003) in the biological domain and have applied the same idea to the social domain in which we consider the practice of biomedical science. We have elsewhere emphasized consensus statements in the making of AD (Gaines and Whitehouse 1998). In the present article, we add a number of other chance, decisive sociocultural moments to the mix of social processes producing AD and MCI. We have not considered in detail here a host of cultural features in the theory and practice of biomedicine with respect to AD. These include implicit, yet highly [End Page 83] implicative, cultural notions of bilateral kinship employed in genetic research on AD considered elsewhere (Gaines 1998).Bavidge's comments are cogent as well. With respect to the notion of my concept of the local biology of "race" (Gaines 2005), it is germane to point out here that such culturally constructed biologies are relevant to a discussion of AD and other dementias. Such constructions represent culture in science. We used the dramatic example of "race" in US biomedicine because it is experiencing a resurgence as an explanatory tool. For example, recently Haiman et al. (2006) presented research that suggests that "Among cigarette smokers, African Americans and native Hawaiians are more susceptible to lung cancer than whites, Japanese Americans and Latinos." The authors assert, as have many US studies, that their findings show differences relate to the alleged biology of the social groups concerned. Their problem and that of others, is that the groups are social, not biological, and most have mixed ancestry and do not stem from distinct groups. This is particularly true of African Americans and Latinos; both groups are substantially composed of individuals with European, West African, and Native American ancestry in widely varying proportions (Gaines 2005). Thus, they are different only in terms of their classification. Such work regularly overlooks influences, such as environmental racism, discrimination, poverty, and a lack of medical care, as well as other practices. These might include, in a study of smoking, pakalolo smoking (local marijuana) among Hawaiians, who themselves are usually part Portuguese, Japanese, Chinese, and or European... (shrink)

BackgroundThe highly sensitive nature of genomic and associated clinical data, coupled with the consent-related vulnerabilities of children together accentuate ethical, legal and social issues (ELSI) concerning data sharing. The Key Implications of Data Sharing (KIDS) framework was therefore developed to address a need for institutional guidance on genomic data governance but has yet to be validated among data sharing practitioners in practice settings. This study qualitatively explored areas of consensus and dissensus of the KIDS Framework from the perspectives (...) of Canadian clinician-scientists, genomic researchers, IRB members, and pediatric ethicists.MethodsTwelve panelists participated in a three-round online policy Delphi to determine the desirability, feasibility, relative importance and confidence of twelve individual statements of the KIDS Framework. Mean and IQR were calculated from panelists’ ratings to determine the strength of consensus and polarity. Qualitative content analysis of panelists’ written responses was used to assess degree of support. Statements were validated when their combined ratings and qualitative rationales indicated high-moderate consensus (at least 70% agreement across two contiguous categories), low to no polarity (IQR at least 1.0) and strong support.ResultsNine original, and one new statement reached consensus. These statements outlined essential elements of the informed consent process, including a realistic evaluation of benefits and risks and assurance of future ethics oversight for secondary data use. Discrepant views on appropriate protections for anonymized and coded i.e. de-identified genomic data were primary sources of dissensus.ConclusionsThe validated statements provide institutions with empirically supported best practices for sharing genomic and associated clinical data involving children from the perspectives of key stakeholders. Concerted efforts to quantify informational risks that can be conveyed to patients and families are further needed to align data sharing policy with stakeholder priorities. (shrink)

Background: Human health is dependent upon environmental sustainability. Many have argued that environmental sustainability advocacy and environmentally responsible healthcare practice are imperative healthcare actions. Research questions: What are the key obstacles to healthcare professionals supporting environmental sustainability? How may these obstacles be overcome? Research design: Data-driven thematic qualitative analysis of semi-structured interviews identified common and pertinent themes, and differences between specific healthcare disciplines. Participants: A total of 64 healthcare professionals and academics from all (...) states and territories of Australia, and multiple healthcare disciplines were recruited. Ethical considerations: Institutional ethics approval was obtained for data collection. Participants gave informed consent. All data were de-identified to protect participant anonymity. Findings: Qualitative analysis indicated that Australian healthcare professionals often take more action in their personal than professional lives to protect the environment, particularly those with strong professional identities. The healthcare sector’s focus on economic rationalism was a substantial barrier to environmentally responsible behaviour. Professionals also feared conflict and professional ostracism, and often did not feel qualified to take action. This led to healthcare professionals making inconsistent moral judgements, and feeling silenced and powerless. Constraints on non-clinical employees within and beyond the sector exacerbated these difficulties. Discussion: The findings are consistent with the literature reporting that organisational constraints, and strong social identification, can inhibit actions that align with personal values. This disparity can cause moral distress and residue, leading to feelings of powerlessness, resulting in less ethical behaviour. Conclusion: The data highlight a disparity between personal and professional actions to address environmental sustainability. Given the constraints Australian healthcare professionals encounter, they are unlikely to shift to environmentally responsible practice without support from institutions and professional associations. Professional development is required to support this endeavour. The poor transference of pro-ecological behaviour from one setting to another is likely to have international implications for healthcare practice. (shrink)

BackgroundStructured, systematic methods to formulate consensus recommendations, such as the Delphi process or nominal group technique, among others, provide the opportunity to harness the knowledge of experts to support clinical decision making in areas of uncertainty. They are widely used in biomedical research, in particular where disease characteristics or resource limitations mean that high-quality evidence generation is difficult. However, poor reporting of methods used to reach a consensus – for example, not clearly explaining the definition of (...) consensus, or not stating how consensus group panellists were selected – can potentially undermine confidence in this type of research and hinder reproducibility. Our objective is therefore to systematically develop a reporting guideline to help the biomedical research and clinical practice community describe the methods or techniques used to reach consensus in a complete, transparent, and consistent manner.MethodsThe ACCORD project will take place in five stages and follow the EQUATOR Network guidance for the development of reporting guidelines. In Stage 1, a multidisciplinary Steering Committee has been established to lead and coordinate the guideline development process. In Stage 2, a systematic literature review will identify evidence on the quality of the reporting of consensus methodology, to obtain potential items for a reporting checklist. In Stage 3, Delphi methodology will be used to reach consensus regarding the checklist items, first among the Steering Committee, and then among a broader Delphi panel comprising participants with a range of expertise, including patient representatives. In Stage 4, the reporting guideline will be finalised in a consensus meeting, along with the production of an Explanation and Elaboration document. In Stage 5, we plan to publish the reporting guideline and E&E document in open-access journals, supported by presentations at appropriate events. Dissemination of the reporting guideline, including a website linked to social media channels, is crucial for the document to be implemented in practice.DiscussionThe ACCORD reporting guideline will provide a set of minimum items that should be reported about methods used to achieve consensus, including approaches ranging from simple unstructured opinion gatherings to highly structured processes. (shrink)

Environmental ethics is a critical study of the normative issues and principles relevant to the relationship between humans and the natural world. It covers various fields, ranging from the welfare of animals versus ecosystems to theories of the intrinsic value of nature. There are various approaches to environmental ethics. This paper examines some of the key positions presented by different environmental ethicists and their impacts on the natural environment. Some writers maintain that environmental ethics does not have a (...) major contribution to make to the solution of environmental problems. However, this study and the contribution of many scholars show that environmental ethics has much to contribute to the solution of global environmental problems. Various governments and policy makers can bring the insights of environmental ethics into various natural resource management settings. The ideas of environmental ethicists have had an impact on the natural environment. Among others, the “Precautionary principle” is an ethical principle that is increasingly being embodied in the legislation of various governments. If environmental ethics broadens its scope and addresses the injustice done to the majority of poor and powerless people and to nonhuman species, it will have a paramount role in creating awareness within countries and globally about the actions of transnational corporations, irresponsible capitalist countries and local industries which damage the environment. Environmental ethicists may alert peasant farmers, pastoralists and other indigenous people to understand the long range effects of environmental degradation that are beyond the purview of local people and otherwise unavailable. Environmental ethicists with varied backgrounds can join peasant farmers and pastoralists who have multidimensional knowledge of the natural environment and help them develop further knowledge of it. The efforts of many people will one day bring change in favour of the majority of the people, nonhuman species, and the planet Earth. In fact, the paper stresses that environmental questions are not simply ethical. It suggests that the present power relations at the local and international levels should be changed in the direction of just and environmentally and socially sound development.EJOSSAH Vol.1 2003: 63-88. (shrink)

Minorities who disagree with the “scientific consensus” must be allowed to air their viewsI will begin by discussing the example used in Schüklenk’s paper1 of the self proclaimed “HIV dissidents” and then discuss whether the recommendations made are useful and could be applied to other examples in science.Schüklenk’s primary concern according to his title is with the professional responsibilities of biomedical scientists engaging in public discourse. The example given is of the effect that self proclaimed HIV dissidents have (...) had on the provision of HIV related public health measures in South Africa. Fundamental to the example given is a distinction that both Schüklenk and indeed the general public often fail to make. It is important to recognise the difference between biomedical science and clinical practice. Science and medicine are two distinct fields, each with their own historically founded methods and purposes; they have had little in common with each other until relatively recently. Schüklenk confuses the two when he judges a scientific hypothesis by its clinical utility."It certainly seemed prudent to me at the time to give support to critics of a hypothesis, the pursuit of which had done little to bring those in need closer to life extending or life saving AIDS drugs."He later reconsiders his position on the basis of new clinical evidence."My own conversion to the mainstream view took place roughly when dissident predictions about AIDS deaths resulting from what they believed were highly poisonous drug cocktails—that is, triple therapy, did not occur, and when it became clear that actually the opposite was true; these drugs were at least life extending. I saw … ". (shrink)

With the end of the cold war, issues of environment and economic development are assuming greater international salience. By the 1970s, environmental degradation was becoming pervasive, with growing global effects. Increasingly, global and emergent globalized problems are forcing environmental interdependence on the world. Transboundary threats cannot be addressed unilaterally by any single country or group of countries. The global environmental agenda is reviving the North-South debate and rejuvenating the Third World coalition in international fora. The encouragement of environmentally sustainable (...) forms of industrialization in the South requires expanded and improved international cooperation. However, the North’s greater resources and greater responsibility in causing global environmental degradation require its continuing involvement in the search for solutions, including ones applicable to newly industrializing countries. In June 1992, the largest intergovernmental conference ever held was convened in Rio de Janeiro to address these issues: the United Nations Conference on Environment and Development (UNCED, or the Earth Summit). It produced a consensus action plan of about 700 pages: Agenda 21. Agenda 21 presents massive challenges for international cooperation as well as for national and private actors and scientific and technical institutions. It reflects a complex configuration of demands for institutional arrangements that support environmentally sustainable technical and socioeconomic change. One of the most consistent of the Agenda 21 themes, and one of the most intractable issues, concerns “access to technology.” This can be as straightforward as diagnosing and improving the efficiency of a production process in a small manufacturing firm, or as complex as engineering a technological revolution in which production and consumption take place with virtually no material or energy loss to the environment. The selection of entry points for action is a critical strategic problem as well as an important operational issue. In this paper I identify and describe new initiatives intended to improve the environmental performance of industry in the South, and find that they largely aim to promote incremental industrial innovation through international technology transfer and diffusion. This strategy raises many questions about how to promote effective technology transfer and diffusion. (shrink)

Environmental philosophy – broadly conceived as using philosophical tools to develop ideas related to environmental issues – is conducted and practised in highly diverse ways in different contexts and traditions in Asia. ‘Asian environmental philosophy’ can be understood to include Asian traditions of thought as well as grassroots perspectives on environmental issues in Asia. Environmental issues have sensitive political facets tied to who has the legitimacy to decide about how natural resources are used. Because of this, the works, practices, (...) and researchers in Asian environmental philosophy are exposed to being (mis)used by diverse stakeholders and actors to support political ends not related to environmental sustainability. Two processes are at play at the nexus of the construction of identities in relation to conceptualisations of nature: eco-orientalism and ecological nationalisms. This paper analyzes and exemplifies these dynamics through a conceptual framework that distinguishes ideological and socio-technical explanations of environmental degradation. Finally, to minimise the risks of political misuse, five pathways are presented to carefully help curate environmental, philosophical statements: contextualise, quantify uncertainty and ‘uniqueness’, downscale, confront claims with local realities and literature, and collaborate with researchers from other disciplines. Conjointly, these pathways aim at favouring intercultural collaboration while valuing diversity, thus supporting the development and exchanges in environmental philosophy in Asia and beyond. (shrink)

The sounds produced by animals have been a topic of research into animal behaviour for a very long time. If acoustic signals are undoubtedly a vehicle for exchanging information between individuals, environmental sounds embed as well a significant level of data related to the ecology of populations, communities and landscapes. The consideration of environmental sounds for ecological investigations opens up a field of research that we define with the term ecoacoustics. In this paper, we draw the contours of ecoacoustics by (...) detailing: the main theories, concepts and methods used in ecoacoustic research, and the numerous outcomes that can be expected from the ecological approach to sound. Ecoacoustics has several theoretical and practical challenges, but we firmly believe that this new approach to investigating ecological processes will generate abundant and exciting research programs. (shrink)

This paper focuses on experiences from a case study dealing with the Swiss type of a consensus conference called “PubliForum” concerning “Genetic Technology and Nutrition” (1999). Societal and ethical aspects of genetically modified food meanwhile can be seen as prototypes of topics depending on the involvement of the public through a participatory process. The important role of the lay perspective in this field seems to be accepted in practice. Nevertheless, there is still some theoretical controversy about the necessity (...) and democratic legitimacy of participatory processes in general, and especially about those dealing with technological or environmental problems (sustainable development) concerning society. From an ethical point of view, a lot of heterogeneous problems concerning contents and procedures of public participation can be pointed out, not only on the theoretical level but also in practice, e.g., concerning the communication process between laypersons and experts. The intention of our paper is to give hints and to clarify criteria that support the communication process leading to a dialog of autonomous citizens and which especially consider ethical aspects in the field. One important result is that there must be an orientation for all members of a consensus conference having clear rules and knowing their different roles that support transparency, credibility, and fairness of the whole procedure and a “good product”: a substantial final document or citizens’ report. (shrink)

CLARE PALMER | : This paper argues that there is no simple rift between animal liberation and environmental ethics in terms of strategies for environmental conservation. The situation is much more complicated, with multiple fault lines that can divide both environmental ethicists from one another and animal ethicists from one another—but that can also create unexpected convergences between these two groups. First, the paper gives an account of the alleged rift between animal liberation and environmental ethics. (...) Then it’s argued that this rift was always exaggerated. For instance, animal ethicists who prioritize aggregate animal welfare have always converged with environmental ethicists in supporting certain cases of hunting and culling, and, in doing so, they have diverged from animal rights theorists, who generally oppose these practices. Pervasive threats such as climate change make it likely that environmental ethicists will also diverge from one another in terms of the conservation strategies they support, depending on what values they prioritize. For instance, conservation strategies that protect species may not necessarily protect other environmental values such as ecosystem flourishing or wildness. The paper concludes that conservation under climate change is likely to bring both new divergences and new convergences, and that these are unlikely to take the form of a rift between animal liberation and environmental ethics. | : Cet article soutient qu’il n’existe pas un clivage simple entre le mouvement de la libération animale et l’éthique environnementale quant aux stratégies de conservation environnementale. La situation est bien plus complexe, de nombreuses lignes de faille pouvant d’une part diviser autant les spécialistes d’éthique environnementale que les spécialistes d’éthique animale et, d’autre part, créer des convergences inattendues entre ces deux groupes. L’article fait d’abord état du prétendu clivage entre le mouvement de la libération animale et l’éthique environnementale, pour ensuite démontrer l’exagération de ce clivage. Par exemple, les spécialistes d’éthique animale qui priorisent le bien-être global des animaux se sont toujours accordé avec les spécialistes d’éthique environnementale pour approuver certains cas de chasse et d’abattage, divergeant par là-même des théoriciens des droits des animaux, qui s’opposent généralement à ces pratiques. De plus, des menaces omniprésentes telles que le changement climatique auront vraisemblablement pour effet de diviser les éthiciens environnementaux selon les stratégies de conservation qu’ils préconisent en fonction de leurs valeurs prioritaires. Ainsi, les stratégies de conservation qui protègent certaines espèces ne protègeront pas nécessairement d’autres valeurs environnementales telles que l’épanouissement des écosystèmes ou la préservation de leur état sauvage. L’article tire la conclusion que, dans le contexte des changements climatiques, la question de la conservation est susceptible de soulever à la fois de nouvelles divergences et de nouvelles convergences, lesquelles ne prendront probablement pas toutefois la forme d’un clivage entre le mouvement de la libération animale et l’éthique environnementale. (shrink)

This study examines the direct impact of three dimensions of the institutional environment on managerial attitudes toward the natural environment and the direct influence of the latter on the environmental sustainability orientation (ESO) of small firms. We contend that when the institutional environment is perceived by owner–managers as supportive of sound natural environment management practices, they are more likely to develop a positive attitude toward natural environment issues and concerns. Such owner–manager attitudes are likely to lead to a (...) positive and proactive orientation of their firms toward environmental sustainability. The study uses survey data from 166 small manufacturing firms located in three Philippine cities. First, the study develops and tests the measurement models to examine the validity of the constructs representing the firm’s institutional environment, managerial attitudes toward the natural environment and the ESO of firms. Second, the study develops and tests the structural models examining the institutional environment–managerial attitudes–ESO linkages. Multi-sample invariance structural model analysis shows the mediating role of managerial attitudes in the institutional environment–ESO nexus. The findings show that ESO is a construct comprising three dimensions: knowledge of environmental issues, sustainable practices and commitment toward environmental sustainability. The cognitive, regulatory and normative elements of the institutional environment are strongly linked to positive managerial attitudes toward environmental sustainability, which in turn, positively influences the firm’s overall ESO. Managerial attitudes play a mediating role in the institutional environment–ESO linkages. The managerial, practical, research and policy implications of the research findings are discussed. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:358 BOOK REVIEWS ing and his arguments seem more tentative and relativistic than those offered in his previously published works (Truth and Other Enigmas, 1978; The Interpretation of Frege's Phuosophy, 1981, etc.). Yet he uses his mastery of powerful logical techniques in order to support the chosen positions. This fact might give great satisfaction to a logician, hut the metaphysician may he somewhat disappointed by the meager results (...) attained, though Dummett himself modestly restricts his goals to those of forming only " a base camp for an assault on the metaphysical peaks...". One may also wonder whether Dummett remained faithful to his methodological requirement of the priority of meaningtheory with regard to logic and metaphysics. Doesn't Dummett's acceptance of intuitionistic logic (with its rejection of the principle of bivalence) dictate his preference for a certain meaning-theory, and not the other way around? To distill and extract metaphysical beliefs and insights which are contained (perhaps tacitly) in the working of our language is undoubtedly a legitimate goal of any philosophical enterprise. But our ambitions go beyond this goal: we are reaching after reality itself, not just after our opinions about reality and their semantical elucidation. In this respect Dummett's programmatic conception of metaphysics may face serious difficulties in attempts to climb the ahovementioned metaphysical peaks. On the other hand, is any metaphysical program exempt from such difficulties? The hook is beautifully printed; Harvard University Press has done an excellent job! The Index, which combines names and subjects, is a hit too economical, omitting certain references (for example, important remarks on God's omniscience on pp. 75-76). AUGUSTIN RISKA Saint John's University New York, New York Ethical Practice in Clinical Medicine. By WILLIAM J. ELLOS. New York: Routledge, 1990. Pp. 190. Medical ethics is an integral part of the science and art of medicine. Rather than being a set of norms or regulations added from external sources, such as the legal norms regulating the medicare program, the norms and maxims of medical ethics are integral elements of medicine arising from the relationship between physician and patient. In one way or another, most philosophers of ethics and medicine would agree with the foregoing statements. But once the role of ethics in medicine has BOOK REVIEWS 359 been established, a serious difficulty arises: What method should he used to define and delineate ethical norms for particular cases? More to the point, how should one go about solving problems in medical ethics? Father William Ellos, S.J., is concerned with resolving the difficulty of method in medical ethics. He seeks to develop and explain a method in medical ethics that will be both clinical and pragmatic. Joining with other specialists in the field, he opts for a virtue-centered approach to solving issues in medical ethics, as opposed to a rulecentered duty-based approach. While not rejecting the ethical method featuring the principles of autonomy, beneficence, and justice derived from W. D. Ross (an approach favored by so many contemporary scholars in the field of medical ethics), he does maintain that these principles are greatly overworked as well as simplistic. He proposes virtue-centered reasoning as a better method of ethical endeavor, especially attuned to the complexity and problematics of clinical ethics. In developing the notion of virtue·centered ethics, Ellos considers the contributions of the past and present thinkers to this method of ethical decision making. Hence, Plato, Aristotle, Thomas, the Scottish Enlightenment Philosophers, and American Pragmatists are the main sources of his reflections upon virtue ethics. Ellos finds a culmination of virtue ethics in the present-day tendency of many consultants in medical ethics to classify themselves as casuists, indicating that they are eclectic and pragmatic in their efforts to solve clinical cases. In the course of the historical and analytical sections of this work, Ellos demonstrates not only a wide acquaintance with classical and contemporary authors but also an ability to discern continuity of thought among these well.known philosophers and theologians. Especially significant is his recognition of the too often neglected contemporary authors Collen Clements and Roger Sider, whose accurate indictment of the principle of autonomy as interpreted by present-day medical ethicists restores the... (shrink)

This book is the result of a three-year study undertaken by a multidisciplinary working party of the Institute of Medical Ethic (UK). The group was chaired by a moral theologian, and its members included biological and ethological scientists, toxicologists, physicians, veterinary surgeons, an expert in alternatives to animal use, officers of animal welfare organizations, a Home Office Inspector, philosophers, and a lawyer. Coming from these different backgrounds, and holding a diversity of moral views, the members produced the agreed report (...) as a result of detailed and rigorous discussions. The book sets out facts about animal experiments and about animal abilities to experience pain, distress and anxiety. There is a detailed examination of the moral claims related to the benefits likely to accrue from animal research, and of strategies for weighing these benefits against the harm caused to animals, in order to decide whether particular research projects ought or ought not to proceed. This leads to consideration of the statutory and non-statutory controls which safeguard standards in such research. The final section explores a variety of philosophical arguments about the use of animals in research, and offers a philosophical justification for the Working Party's more practical conclusions. Written in clear, nontechnical language, this book is accessible to lay people as well as to scientists. It is the first such document to emerge from a meeting of people with such widely differing views on this highly controversial subject, and represents a major contribution towards informing and raising the quality of contemporary debate. The book is unique in drawing together material and ideas never before found in one volume. It will interest a broad spectrum of readers, from ethicists and animal rights advocates to scientific researchers and laboratory administrators, along with general readers concerned about this compelling issue. (shrink)

PHOTO ID 121339257© Designer491| Dreamstime.com ABSTRACT When physicians use their clinical knowledge and skills to advance the well-being of their patients, there may be apparent conflict between patient autonomy and physician beneficence. We are skeptical that today’s medical ethics education adequately fosters future physicians’ commitment to beneficence, which is both rationally defensible and fundamentally consistent with patient autonomy. We use an ethical dilemma that was presented to a group of third-year medical students to examine how ethics education might be causing (...) them to give undue deference to autonomy, thereby undermining their commitment to beneficence. INTRODUCTION The right of patients to choose which treatments they prefer is rooted in today’s social mores and taught as a principle of medical ethics as respect for autonomy. Yet, when physicians use their clinical knowledge and skills to advance the well-being of their patients, there may be a conflict between patient autonomy and physician beneficence. We are skeptical that today’s medical ethics education adequately fosters a commitment to beneficence, which is both rationally defensible and fundamentally consistent with patient autonomy. I. An Ethical Dilemma The impetus for this paper arose when students who were completing their third clinical year discussed a real-life ethical dilemma. A middle-aged man developed a pulmonary hemorrhage while on blood thinners for a recently placed coronary stent. The bleeding was felt to be reversible, but the patient needed immediate intubation or he would die. The cardiologist was told that the patient previously expressed to other physicians that he never wanted to be intubated. However, the cardiologist made the decision to intubate the patient anyway, and the patient eventually recovered.[1] Students were asked if they believed that the cardiologist had acted ethically. Their overwhelming response was, “No, the patient should have been allowed to die.” We looked into how students applied ethical reasoning to conclude that this outcome was ethically preferred. To explore how the third-year clinical experience might have formed the students’ judgment, we presented the same case to students who were just beginning their third year. Their responses were essentially uniform in recommending intubation. While there is likely more than one reasonable view in this case, we agree with the physician and the younger medical students that intubation was the ethically appropriate decision and will present an argument for it. But first, we explain the reasoning behind the more advanced medical students’ decision to choose patient autonomy at the expense of beneficence. II. Medical Ethics Education and the Priority of Autonomy Beauchamp and Childress’s Principles of Biomedical Ethics, first published in 1979 and now in its 8th edition, is a significant part of the formal ethics education in medical school.[2] Students learn an ethical decision-making approach based on respect for four ethical principles: autonomy, beneficence, nonmaleficence, and justice. While Beauchamp and Childress officially afford no prima facie superiority to any principle, the importance of respect for patient autonomy has increased through the editions of their book. For example, early editions of their book opposed the legalization of physician-assisted death compared to recent editions that defended it.[3] As another example, Beauchamp and Childress make paternalism harder to justify by adding an autonomy-protecting condition to the list of conditions for acceptable paternalism.[4] Authority, they contend, need not conflict with autonomy—provided the authority is autonomously chosen.[5] “The main requirement,” they write, “is to respect a particular patient’s or subject’s autonomous choices, whatever they may be.[6] In the principlism of Beauchamp and Childress, autonomy now seems to have a kind of default priority.[7] However, the bioethics discourse has strong counternarratives, noting some movement to elevate the role of beneficence and to respect the input of stakeholders, including the family and the healthcare team. Ethics education achieves particular relevance in the third clinical year when students become embedded in the care of patients and learn from what has been called the informal curriculum. They observe how attending physicians approach day-to-day ethical problems at the patient’s bedside. In this context, students observe the importance of informed consent for serious treatments or invasive procedures, a practice that highlights the principle of patient autonomy. In both the formal and informal curriculum, medical students observe how, in the words of Paul Wolpe, “patient autonomy has become the central and most powerful principle in ethical decision-making in American medicine.”[8] In short, students appear to learn a deference for patient autonomy. This curricular shift in favor of autonomy coincides with legal developments that protect patients’ rights and decision-making with respect to their healthcare choices. The priority of autonomy in medicine benefits patients by reflecting their choices and, in some cases, their fundamental liberty. III. The Practice of Medicine and the Commitment to Beneficence There are many critiques of the dominant place that autonomy has in biomedical ethics,[9] especially considering that autonomy seems to be biased toward individualistic, Western, and somewhat American culture-driven values.[10] In addition, many bioethical dilemmas are cast as a conflict between autonomy and beneficence. Our point is that medical students bring to their study of medicine a commitment to beneficence that seems to be suppressed by practical ethics education. We think this commitment is rationally defensible and should be nurtured. It is striking that young medical students have a pre-reflective commitment to beneficence at all. For, as we mentioned, it is not just medicine but Western culture generally that prioritizes autonomy in settling ethical dilemmas. In wanting to act for the good of others (rather than simply agreeing to what others want), physicians are already swimming somewhat against the cultural tide.[11] However, doing so makes sense, given the nature of medicine and the profession of healing. When prospective medical students are asked why they wish to become physicians, the usual answer is some variation on caring for the sick and preventing disease. It is unlikely that a reason to become a physician is to respect a patient’s autonomy. It would be easy to dismiss medical students’ commitment to beneficence as a mere intuition and contrary to a more reasoned and deliberative approach. Beauchamp and Childress seem to minimize the value of physician intuition, stating that justifications for certain procedures are “…supported by good reasons. They need not rest merely in intuition or feeling.”[12] Henry Richardson writes that “situational or perceptive intuition…leaves the reasons for decision unarticulated.”[13] We think this is a crude and rather thin way of understanding intuition. Some bioethicists have defended intuition as essential to the practice of medicine and not something opposed to reason.[14] In the case we describe, we believe the ethical justifications s for the patient’s intubation are fundamentally sound: the patient did not have a “do not intubate” order written in the chart, the emergency intubation had not been foreseen, so the patient did not have the opportunity to consent to or reject intubation; the patient had consented to the treatment for his cardiac disease so his consent for intubation could have been assumed;[15] and the consequences of respecting his autonomy did not justify allowing him to die.[16] While it is possible to have more than one reasonable view on this case, we think the case for beneficence is strong and certainly should not be dismissed out of hand. We do not deny that if a patient makes a clearly documented, well-informed decision to forgo intubation that this decision ought to be respected by the physician (even if the physician disagrees with the patient’s decision). But, in this situation, as in many others in the practice of medicine, the patient’s real wishes and preferences are not well-articulated in advance. There are many cases where a physician acts based on what she believes the patient, or the surrogate, would want, sometimes in situations that do not allow much time for reflection. An example might be resuscitation of a newborn at the borderline of viability. In their ethics education, beneficence would mean acting first to save a life. If the patient or surrogate makes an informed decision to the contrary, a beneficent physician respects that autonomous decision. In the case presented, the patient expressed gratitude to the cardiologist when extubated. But what if he had expressed anger at the physician for violating his autonomy? There are those who could argue that not only was intubation ethically wrong but that the cardiologist put himself in legal jeopardy by his actions (especially if there had been a written refusal applicable to the specific situation). In the example we use, we point out that the cardiologist may not have escaped a lawsuit if the patient had died without intubation. His family, when hearing the circumstances, may have sued for failure to act and dereliction of the cardiologist’s duty to save him. Beyond a potential legal challenge for either action or inaction, there is an overriding ethical question the cardiologist had to address: what course would be most satisfying to his conscience? Would he rather allow a patient to die for fear of recrimination, or act to save his life, regardless of the personal consequences? In the absence of real knowledge about the patient’s considered wishes, it is most reasonable to err on the side of promoting patient well-being. A physician’s commitment to beneficence is not necessarily a way of undermining a patient’s autonomy. In acting for the patient's good, physicians are also acting on what it is reasonable to believe a patient (or most patients, perhaps) would want, which is obviously connected to what a patient does want. Pellegrino and Thomasma argue that beneficence includes respect for a patient’s autonomy since “the best interests of the patient are intimately linked with their preferences.”[17] Instead of conceptualizing ethical dilemmas in medicine as conflicts between autonomy and beneficence, it is possible that medical schools could teach students that truly practicing beneficence is a way of valuing patient autonomy, especially when the patient’s wishes are not specific to the situation and are not clearly expressed. CONCLUSION It is important for students and practicing physicians to understand the principle of respect for patient autonomy in a pluralistic society that demands personal self-determination. However, the role of the physician as a beneficent healer should not be diminished by this respect for autonomy. Respecting a patient’s autonomy is grounded in and manifested by physician beneficence.[18] That is, seeking what is good for the patient can only be good if it respects their personhood and dignity. We propose that a commitment to beneficence, incipient in young medical students, should be developed over time with their other clinical reasoning skills. Such a commitment need not be sacrificed on the altar of patient autonomy. Beneficence needs greater relative moral weight with students as they proceed in their ethics education. - [1] S. Jauhar, “When Doctors Need to Lie,” New York Times, February 22, 2014, https://www.nytimes.com/2014/02/23/opinion/sunday/when-doctors-need-to-lie.html. [2] T. L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 8th ed. (New York, NY: Oxford University Press, 2019). [3] Louise A. Mitchell, “Major Changes in Principles of Biomedical Ethics,” The National Catholic Bioethics Quarterly 14, no. 3 (2014): 459–75, https://doi.org/10.5840/ncbq20141438. [4] Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 8th ed. (New York, NY: Oxford University Press, 2019), 238. [5] Beauchamp and Childress, 103. [6] Beauchamp and Childress, p. 108. [7] For other accounts that prioritize autonomy, see e.g. Allen E. Buchanan and Dan W. Brock, Deciding for Others: The Ethics of Surrogate Decision Making (Cambridge University Press, 1989), 38–39; R Gillon, “Ethics Needs Principles—Four Can Encompass the Rest—and Respect for Autonomy Should Be ‘First among Equals,’” Journal of Medical Ethics 29, no. 5 (October 2003): 307–12, https://doi.org/10.1136/jme.29.5.307. For examples of critiques of these accounts, see footnote 9. [8] P. R. Wolpe, “The Triumph of Autonomy in American Bioethics: A Sociological View,” in Bioethics and Society: Constructing the Ethical Enterprise, p. 43. [9] V. A. Entwistle et al., “Supporting Patient Autonomy: The Importance of Clinician-Patient Relationships,” Journal of General Internal Medicine 25, no. 7 (July 2010): 741–45; C. Foster, Choosing Life, Choosing Death: The Tyranny of Autonomy in Medical Ethics and Law, 1st ed. (Oxford ; Hart Publishing, 2009); O. O’Neill, Autonomy and Trust in Bioethics, The Gifford Lectures, University of Edinburgh 2001 (Cambridge, UK: Cambridge University Press, 2002). [10] P. Marshall and B. Koenig, “Accounting for Culture in a Globalized Bioethics,” The Journal of Law, Medicine & Ethics: A Journal of the American Society of Law, Medicine & Ethics 32, no. 2 (2004): 252–66; R. Fan, “Self-Determination vs. Family-Determination: Two Incommensurable Principles of Autonomy,” Bioethics 11, no. 3–4 (1997): 309–22. [11] Arguments stressing the importance of beneficence, as ours does here, certainly approach paternalistic arguments. We set aside the complex issue of paternalism for purposes of this paper and simply note that the principle of beneficence as such does not say anything specifically about acting against the patient’s will. In the case study that focuses this paper, we do not believe the patient’s will or wishes were clearly indicated. [12] Beauchamp and Childress, Principles of Biomedical Ethics, p. 20, see note 2 above. [13] H. S. Richardson, “Specifying, Balancing, and Interpreting Bioethical Principles,” The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine 25, no. 3 (January 1, 2000): 285–307, p. 287. [14] H. D. Braude, Intuition in Medicine a Philosophical Defense of Clinical Reasoning (Chicago ; University of Chicago Press, 2012). [15] R. Kukla, “Conscientious Autonomy: Displacing Decisions in Health Care,” The Hastings Center Report 35, no. 2 (2005): 34–44. [16] M. Schermer, The Different Faces of Autonomy: Patient Autonomy in Ethical Theory and Hospital Practice, vol. 13, Library of Ethics and Applied Philosophy (Dordrecht: Springer Netherlands, 2002). [17] E. D. Pellegrino and D. C. Thomasma, For the Patient’s Good - the Restoration of Beneficence in Health Care (New York, NY: Oxford University Press, 1988), p. 29. [18] Pellegrino and Thomasma, For the Patient’s Good. 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The World Professional Association for Transgender Health guidelines Standards of Care 8 draw on ethical arguments based on individual autonomy, to argue that healthcare and other professionals should be advocates for trans people. Such guidelines presume the presence of medical services for trans people and a degree of consensus on medical ethics. Very little is known, however, about the ethical challenges associated with both providing and accessing trans healthcare, including gender affirmation, in the Global South. In light (...) of the challenges associated with medical and legal gender affirmation in Indonesia, we conducted a qualitative study to understand the views of trans people, healthcare providers, and legal practitioners. In this qualitative study, we drew on a participatory methodology to conduct 46 semi-structured interviews between October and December 2023, with trans people (10 trans feminine people and 10 trans masculine people, each interviewed twice) and key informants (three healthcare providers and three lawyers and paralegals). Trans people were a central part of the research team from inception through to analysis and writing. Participants were recruited via community-led sampling. Data analysis of interview data took place through an immersion/crystallisation technique and preliminary inductive coding which highlighted key quotes. We focused on an inductive analysis using participant narratives to identify key concepts in the ethics of gender affirmation in Indonesia. We characterize the ethics of supportive healthcare workers, community members, and family members, as that akin to “accomplices,” a concept of ethics used in theories of racial justice which evaluate a willingness to support people to navigate laws and regulations which perpetuate injustices and violence. Overall, both trans people and key informants shared an understanding that the legal status of gender-affirming medical care was particularly ambiguous in Indonesia due to a lack of clarity in both laws and regulations. For trans participants, ethical arguments for the validity of legal and medical gender affirmation was premised on evidence that their gender identity and expression was already recognized within society, even if limited to immediate friends and family. Given that all participants expressed a desire for gender affirmation, but such services were widely unavailable, accomplices played a crucial role in supporting trans people to access healthcare. An empirical study based on an “ethics from below” helps to show that arguments grounded in autonomy, or based on biomedical evidence, are unlikely to alter unjust laws or facilitate a change to pathologizing guidelines governing understanding of trans people’s healthcare and legal needs in Indonesia. We provide an analysis that is sensitive to the ethics of facilitating gender affirmation in a context where that process is inherently social, and often articulated in relation to a prevailing religious morality. (shrink)

Summary Principles Timely support for patients and people close to them, and effective, sensitive communication are essential. Decisions must be based on the individual patient's circumstances and reviewed regularly. Sensitive advance discussion should always be encouraged, but not forced. Information about CPR and the chances of a successful outcome needs to be realistic. Practical matters Information about CPR policies should be displayed for patients and staff. Leaflets should be available for patients and people close to them explaining about CPR, (...) how decisions are made and their involvement in decisions. Decisions about attempting CPR must be communicated effectively to relevant health professionals. In emergencies If no advance decision has been made or is known, CPR should be attempted unless: the patient has refused CPR; the patient is clearly in the terminal phase of illness; or the burdens of the treatment outweigh the benefits. Advance decision making Competent patients should be involved in discussions about attempting CPR unless they indicate that they do not want to be. Where patients lack competence to participate, people close to them can be helpful in reflecting their views. Legal issues Patients' rights under the Human Rights Act must be taken into account in decision making. Neither patients nor relatives can demand treatment which the health care team judges to be inappropriate, but all efforts will be made to accommodate wishes and preferences. In England, Wales and Northern Ireland relatives and people close to the patient are not entitled in law to take health care decisions for the patient. In Scotland, adults may appoint a health care proxy to give consent to medical treatment. Health professionals need to be aware of the law in relation to decision making for children and young people.IntroductionWhy policies are neededCardiopulmonary resuscitation can be attempted on any person whose cardiac or respiratory functions cease. Failure of these functions is part of dying and thus …. (shrink)

This paper analyzes the determinants underlying the internalization of proactive environmental management proposed by certifiable environmental management systems such as those set out in ISO 14001 and the European Management and Auditing Scheme. Using a study based on 232 usable questionnaires from EMAS-registered organizations, we explored the influence of institutional pressures from different stakeholders and the role of corporate strategy in the “substantial” versus “symbolic” integration of environmental practices. The results highlighted that although institutional pressures generally strengthen (...) the internalization of proactive environmental practices, the influence of stakeholders can either support the integration of these practices or encourage their superficial adoption. For example, while pressure from suppliers and shareholders contribute to corporate greening, pressure from customers and industrial associations tend to encourage greenwashing. Product quality-oriented strategies also positively influence EMS internalization. The paper sheds light on the institutional complexity underlying the substantial versus symbolic implementation of environmental practices, and questions the dominant isomorphic view of EMS adoption. The paper also bridges the gap between complementary approaches on corporate greening, notably neo-institutional and stakeholder theories. (shrink)

Discrepancies between the Uniform Determination of Death Act (UDDA) and the adult and pediatric diagnostic guidelines for brain death (BD) (the “Guidelines”) have motivated proposals to revise the UDDA. A revision proposed by Lewis, Bonnie and Pope (the RUDDA), has received particular attention, the three novelties of which would be: (1) to specify the Guidelines as the legally recognized “medical standard,” (2) to exclude hypothalamic function from the category of “brain function,” and (3) to authorize physicians to conduct an (...) apnea test without consent and even over a proxy’s objection. One hundred seven experts in medicine, bioethics, philosophy, and law, spanning a wide variety of perspectives, have come together in agreement that while the UDDA needs revision, the RUDDA is not the way to do it. Specifically, (1) the Guidelines have a non-negligible risk of false-positive error, (2) hypothalamic function is more relevant to the organism as a whole than any brainstem reflex, and (3) the apnea test carries a risk of precipitating BD in a non-BD patient, provides no benefit to the patient, does not reliably accomplish its intended purpose, and is not even absolutely necessary for diagnosing BD according to the internal logic of the Guidelines; it should at the very least require informed consent, as do many procedures that are much more beneficial and less risky. Finally, objections to a neurologic criterion of death are not based only on religious belief or ignorance. People have a right to not have a concept of death that experts vigorously debate imposed upon them against their judgment and conscience; any revision of the UDDA should therefore contain an opt-out clause for those who accept only a circulatory-respiratory criterion. (shrink)

In all western countries health care budgets are under considerable constraint and therefore a reflection process has started on how to gain the most health benefit for the population within limited resource boundaries. The field of ethics of resource allocation has evolved only recently in order to bring some objectivity and rationality in the discussion. In this article it is argued that priority setting is the prerequisite of ethical resource allocation and that for purposes of operationalization, instruments such as need (...) assessment and health technology assessment (HTA) are essential worktools for making more rational decisions. Thresholds (deduced from the need assessment and HTA) are - within this context - guiding but not binding principles. -/- Discussion of theoretical concepts of not only priority setting, need assessment and HTA complemented by practical examples for showing the challenges and the need, but also the chances of a more explicit and transparent policy of resource allocation in health care. Results: Priority setting in health care is based on the values of equity, justice and solidarity. Health packages decisions are determined from medical need (the severity of the condition) and/or the appropriateness of medical interventions (their cost-effectiveness). With growing awareness that originally effective and cost-effective services and programmes are eventually provided inappropriately, the focus is shifting towards the organisational aspects of provision and application. Therefore, need assessment is based on the distinction of health care needs from demand, supply, or actual care. Additionally HTA provides the evidence on health care interventions in a way that it becomes obvious who benefits from an intervention and who definitely does not benefit, but eventually is harmed. -/- Health services research on effective and cost-effective interventions and research/monitoring of performance that the effective and cost-effective services are provided appropriately are of increasing importance for guiding the decision-making process on priority setting and need assessment. Effective healthcare for all is sustainable, if we start to put expenditures in perspective and focus health policies and research strategies on managing expectations through patient information and a more realistic notion of medical advancements and, on the other hand, on encouraging need-based and cost-effective innovations. (shrink)

The 6th Consensus Statement on Concussion in Sport is authored by the Concussion in Sport Group (CiSG) and intends to provide evidence-based recommendations on concussion management for the welfare of sports participants. However, the authors of the Consensus Statement have declared many competing links to third-party groups. While the declaration of an author’s competing interests is now a widely accepted practice within academic publishing aimed at greater transparency and research integrity, it is not a measure to (...) remove the potential influence of third-party links. In the case of the Consensus Statement, this leaves uncertainty about how the potential sources of third-party bias declared by individual members of the CiSG may have influenced the CiSG’s interpretation of the existing state of evidence on concussion management and impacted the content of the recommendations contained with the Consensus Statement. Openly declaring third-party links falls short of securing trustworthiness in the Consensus Statement recommendations since it leaves end-users of the Consensus Statement with the task of interpreting the impact(s) of these competing interests with little information to guide them. This is because the authors themselves offer neither explanation nor guidance concerning potential bias arising from the competing interests that they have declared, which impinges upon the ability of readers to evaluate the trustworthiness of the content. The status quo could be improved by excluding researchers who have conflicts of interest. Nevertheless, if authors with competing interests are permitted to be part of the CiSG (as is the status quo), then I propose a novel option for increasing transparency that would require authors of the Consensus Statements to provide a reflexive explanation, not simply a declaration, of their competing interests. (shrink)

Nanotechnology has from its very beginning been surrounded with an aura of novelty. For instance, on the 28 introductory pages of the report that prepared the US National Nanotechnology Initiative (NNI), Nanotechnology Research Directions (NSTC/IWGN 1999), we read 73 times the term “new”, 15 times “novel”, 7 times “innovation”, and 21 times “revolution”. The authors concede that one should distinguish between different nanotechnologies, because “Many existing technologies do already depend on nanoscale processes. Photography and catalysis are two examples of (...) ‘old’ nanotechnologies” (ibid, p. xxvi). One might conclude here that, if all the existing nanotechnologies are “old” nanotechnologies, “new” nanotechnologies do not yet exists but are only promises of the future. However, without further explanation and distinction between presence and future, they suggest that most nanotechnologies are or will be new. Furthermore, they claim that nanotechnology (in singular) is a generator of further new technologies, since “Nanotechnology will give birth to new fields that at present are only visions of leading researchers” (ibid., p. xviii). Whenever science managers speak of nanotechnology (in singular), sophisticated distinctions seem to give way to plain claims about the present and future novelty of nanotechnology. As the NNI director Mihail Roco wrote in a 2001 report, “A revolution is occurring in science and technology […] Nanotechnology will fundamentally transform science, technology, and society. In 10 to 20 years, a significant proportion of industrial production, healthcare practice, and environmental management will be changed by the new technology.” (Roco & Bainbridge, pp. 1, 19) When they put on their hats as science managers, scientists rarely reject but mostly support such novelty claim, as did for instance the chemists George Whitesides and Paul Alivisatos in the earlier report: “Nanostructures are the entry into a new realm in physical and biological science.” (NSTC/IWGN 1999, p.. (shrink)

Background: Priority setting is necessary in current healthcare services. Discussion of fair process has highlighted the value of developing reasons for allocation decisions on the basis of experience gained from real cases.Aim: To identify the reasons that those with experience of real decision-making concerning resource allocation think relevant in deciding on the priority of a new but expensive drug treatment.Methods: Semistructured interviews with members of committees with responsibility for making resource allocation decisions at a local level in the (...) British National Health Service, analysed using modified grounded theory.Results: 22 interviews were carried out. 14 reasons were identified. Four reasons were almost universally considered most important: cost effectiveness; clinical effectiveness; equality and gross cost. No one reason was considered dominant. Some considerations, such as political directives and fear of litigation, were thought by many participants to distort decision-making. There was a substantial lack of agreement over the relevance of some reasons, such as the absence of alternative treatment for the condition.Conclusions: There is a clear consensus on the importance and role of a limited number of reasons in allocation decisions among participants. A focus on the process of decision-making, however, does not obviate the need for those involved in the process to engage with problematical ethical issues, nor for the importance of further ethical analysis. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:Towards a Realist Philosophy of History by Adam TimminsAviezer TuckerTIMMINS, Adam. Towards a Realist Philosophy of History. Lanham, Md.: Lexington Books, 2022. 192 pp. Cloth, $95.00The debate about scientific realism, whether science represents reality or just discovers measurements and correlations that are followed by theoretical stories about them, is at the center of the philosophy of science. One potent and frequently discussed antirealist argument has been Larry Laudan’s (...) “pessimistic induction”: Historically, all scientific theories, especially in physics, have been proven false. Hence, all contemporary scientific theories will be proven false and science cannot represent reality. This pessimistic induction relies on knowledge of the history of science, on historiographic realism. Luckily for the pessimistic induction, the history of historiography, the scientific representation of the human past, supports an optimistic induction: Since the revolutions associated with Ranke in historiography, Lyle in geological history, and Darwin in biological history, the historical sciences have made progress but have not [End Page 368] overhauled the founders’ representations of the past. We know more about the human past than Ranke did and much more about the biological past than Darwin did, but the modern historical sciences have not overturned their theories and conclusions. Though there are many new methodologies, historians still go to the archives to compare primary sources, and biologists still study fossils and assume natural selection.Though scientific antirealism assumes historiographic realism, it has received scant philosophic attention. Often it is perceived or presented as a naive “empiricist” concept of historiography that imagines historians “observe” history and then describe it in historiography. Radical antirealist theories of historiography that reduce it to fiction, myth, or manipulative ideology use this image of realism as naive empiricism to dialectically support its equally naive antirealist antithesis. Both ignore the evidential, mostly testimonial, justifications of historiography.Adam Timmins’s project is to articulate and justify a sophisticated historiographic realism that fits historiographic practices and premises. He argues that historiography is “successful in providing information and understanding about the historical past that is constrained by and reflects what actually happened in the past itself.”Timmins’s historiographic realism springs out of the philosophy of language rather than epistemology or philosophy of science. This distinguishes it from Murray Murphey’s historiographic realism, which argued that historiographic ontology is theoretical. Famously, Murphey compared George Washington to the electron as two well-corroborated but unobservable theoretical entities. Timmins retorts that Washington is a proper name and not a theoretical concept, and it is impossible to conduct experiments with Washingtons. Timmins inquires how the language historians use may be interpreted as referring to past events and how historiography can represent history. He does not devote much attention to how historians justify their statements about history to a degree that may warrant a realistic interpretation of historiography. Rather, Timmins assumes so. He proceeds through polemical dialogues with philosophers of historiography who took antirealist stances like Leon Goldstein, Frank Ankersmit, and Jouni Kuukkanen.Timmins’s realism is founded on the belief in a universally accepted core of historiographic facts. He does not inquire about the theoretical foundations of historiographic inferences that allow the emergence of such a consensus. Rather than consider historiographic epistemology, the critical methods of historiography, Timmins considers linguistic communities and entrenched uses of language. He confronts the problem of reference to the past in the absence of its perception by asserting that historiographic representations are of “mental files” that have names (for example, “the Renaissance,” “the Second World War”) and evolving core facts about those historical events (for example, Petrarch and Da Vinci in the Renaissance, the main battles in the war). Though the exact contents of these files may differ between historians, they still refer to the same events and have the same labels. Timmins suggests that experts gradually introduce fluid norms of reference on the basis of broadly accepted facts [End Page 369] whose references caused information chains that led to them. He suggests that complex or colligated concepts are in the mind but refer through mediation to some directly referenced events. For example, the First World War is a concept that through the mediation of facts like its main battles refers to real... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Future of Environmental PhilosophyBen A. Minteer (bio)I think we should be deeply concerned about the future of environmental philosophy. It is the most marginalized of the applied ethics fields (which are often marginalized as a whole within traditional philosophy departments) and with few exceptions, it still has not made significant inroads into neighboring territories—including schools of public policy, natural resources/environment, planning, life sciences, and so on. In my (...) opinion, this is partly due to the general ideological pitch of the field and its narrow methodological orientation, at least historically. The neglect of alternative methods of inquiry, especially qualitative and quantitative work in the social sciences, is particularly troubling.Environmental ethics also has an image problem. In my experience, most natural resource professionals, policy scholars, engineers, and life scientists view our field with considerable skepticism, shaking their heads at what they see as arcane debates that do not touch upon the issues and challenges that motivate their own work. Many of our colleagues in the natural and environmental social sciences, for example, have little patience for the kind of metaethical discussions about intrinsic value, moral pluralism, etc., that have captured much of our attention in the past. They do not see what these kinds of arguments contribute to the scientific, policy, and management curricula, or what they add to their graduate students' training, or to their own research proposals. Typically, if a role for an environmental ethicist is recognized in such settings, it is often just to plug a personnel hole in an National Science Foundation proposal or to serve as a third or fourth reader on a graduate studies committee. Environmental ethics is at best an elective pursuit, it is not seen as essential.I'll be the first to admit that I have blood on my hands here (as do all of us, at least to the extent we have spent time and energy on debates over metaphilosophical issues in the field). And, of course, just because our environmental science and policy colleagues often do not see the true value of the field does not mean that it has no value. Still, I worry that the field seems to be falling into the chasm between traditional philosophy departments and environmental science, policy, and management programs. It is frequently deemed too applied and practical by many [End Page 132] philosophy departments, and too esoteric for schools of public policy, life sciences, and so on. This is not a good situation.How can we fix the image problem? Perhaps one approach would be to develop more solid links with our bioethics cousins (both philosophically and institutionally). There is a revealing story here about the different fortunes of bio- and environmental ethics, and I think we might learn from the success of the former. There will be barriers to such an alliance, however, some of which are intellectual (e.g., the rejection of conventional ethical categories and theories by many environmental ethicists is not shared by most bioethicists) while others are institutional (e.g., What practical shape would a "clinical" model of environmental ethics take? What is the market for this service? and so on).Another route would be to provide more organized and systematic attention to emerging, large-scale environmental science and policy issues—climate change, sustainability, poverty alleviation, and biodiversity loss, to name a few—that are (unfortunately, given their seriousness) viewed as "growth areas" in environmental science and policy studies. At my own institution (Arizona State University) we are moving away from an older departmental and disciplinary model to a more integrative institutional form and a transdisciplinary research culture. So, for example, we have a new school of global studies, a new school of sustainability, and so on. These are composed of a range of disciplines cutting across the natural, technical, and social sciences. There is certainly room in these initiatives and programs for a practical and progressive environmental ethics, but it must be conversant in subjects such as intergenerational equity, conservation science, economic valuation, environmental justice, and the normative dimensions of environmental science policy. I think there is an important role for us to play in these sorts of endeavors (which are popping... (shrink)

This research explores the experiences of UK NHS healthcare professionals working with asylum applicants housed in contingency accommodation during the COVID-19 pandemic. Using a critical understanding of the concept of moral resilience as a theoretical framework, we explore how the difficult circumstances in which they worked were navigated, and the extent to which moral suffering led to moral transformation. Ten staff from a general practice participated in semistructured interviews. Encountering the harms endured by people seeking asylum prior to (...) arrival in the UK and through the UK’s ‘Hostile Environment’ caused healthcare staff moral suffering. They responded to this in several ways, including: (1) feeling grateful for their own fortunes; (2) defining the limitations of their professional obligations; (3) focusing on the rewards of work and (4) going above and beyond usual care. Although moral resilience is reflected in much of the data, some participants described how the work caused ideological transformations and motivated challenges to systems of oppression. We show how current moral resilience theory fails to capture these transformative political and social responses, warning of how, instead, it might encourage healthcare staff to maintain the status quo. We caution against the widespread endorsement of current formulations of moral resilience in contemporary social and political climates, where the hostile and austere systems causing suffering are the result of ideological political decisions. Future work should instead focus on enabling working conditions to support, and developing theory to capture, collective resistance. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Does Meditation Solve the Situationist Crisis in Modern Ethics? A Contemplative Response to John M. DorisMatthew Spencer (bio)There is a good chance you believe in character, in the notions of good character and bad character.1 You may believe in the virtues, too. The virtues are classically said to lead us toward the good, toward the noble, the fine, the honorable (to kalón, to kalon).2 But John M. Doris wants (...) you [End Page 555] to forget about, or move on from, all this talk of virtue and character. There are two suggestions, then: (1) forgetting, (2) thinking about moving on. The two stories are different, and Doris has supported both, sometimes pushing back against his own earlier statements.3 Both stories are powerful, and if we do not assess how they overlap, we will not be in good ethical shape for the future.Why does Doris criticize virtues and character? Virtues, according to the ancient sources, encourage and facilitate our having good ethical dispositions (Anscombe 1958; Keown 1992). If this is right, we ought to have the right kind of (what psychologists today call) traits and, moreover, we can have them.4 Notice, however, that while the virtues may contain or include the having of dispositions, they also extend beyond mere dispositions.According to Aristotle, cultivating courage is to be seen primarily, even exhaustively, as a matter of developing and maintaining the disposition (trait) of courage (Nic. Eth. 1115a6 ff.). However, as others have recognized,5 isolated acts of bravery still count when it comes to calling someone courageous. If you haul a stricken victim from train tracks, you merit the appellation “courageous” even if (especially if) you usually show opposite traits like non-courageousness or cowardice.Furthermore, according to modern virtue ethicists (Russell 2013, pp. 1–28), we must not only have good dispositions but also relate the virtues to the long tradition of what moral philosophy has noticed about the interplay of virtues and character with the moral life in general. Reducing this “moral life” to dispositional virtues is, as the train example indicates, not as attractive as recent writing on virtue ethics suggests.6Because virtues include even if they are not limited to the right kind of traits, they keep us stably disposed to do the right thing whatever the situation. At least, that is the classical picture. The virtues under classical description impact a range of ethically relevant traits, although do note that what “ethical relevance” amounts to is a deep if underexamined question in philosophical ethics; the meanings of “ethical” and “moral” have evolved over time and have not operated in all cultures.Not all cultures, then, have the notions of “moral” and “ethical” that we have, more or less intelligibly, in our own day.7 Arguably, these notions were foreign to Aristotle, as several philosophers from Elizabeth Anscombe to Alasdair MacIntyre have claimed. It may, moreover, be the case that they remained foreign through the early stages of the Western philosophical tradition, much as they also appear foreign to traditions such as Buddhism (MacIntyre 2013, p. 46). The notion that there is some distinguishable realm of “moral matters” as opposed to “nonmoral” matters or to some equally distinguishable realm of “the ethical” is, then, hard to find in the Nicomachean Ethics—despite the name that posterity has given it, with some irony.8 I do not believe the notion can be found, nor that it is named, in the earliest Buddhist texts.9 [End Page 556]The virtues, in any case, are classically designed (arguably in both Aristotle’s works and Buddhism) to give us good ethical dispositions. It is not much use just having a disposition; we need to put it into practice. Defeasible dispositions, in the jargon, do not count for very much—or they do not always count when it matters. The notion, then, that we can have a disposition but not always act upon it because it gets defeated, is controversial.10 How we avoid this fate is a central theme in Aristotle’s Nicomachean Ethics. Then it matters that, for some years now, Doris has criticized the virtues in ancient and modern authors, deprecating... (shrink)

Machine learning-driven clinical decision support systems (ML-CDSSs) seem impressively promising for future routine and emergency care. However, reflection on their clinical implementation reveals a wide array of ethical challenges. The preferences, concerns and expectations of professional stakeholders remain largely unexplored. Empirical research, however, may help to clarify the conceptual debate and its aspects in terms of their relevance for clinical practice. This study explores, from an ethical point of view, future healthcare professionals’ attitudes to potential changes of (...) responsibility and decision-making authority when using ML-CDSS. Twenty-seven semistructured interviews were conducted with German medical students and nursing trainees. The data were analysed based on qualitative content analysis according to Kuckartz. Interviewees’ reflections are presented under three themes the interviewees describe as closely related: (self-)attribution of responsibility, decision-making authority and need of (professional) experience. The results illustrate the conceptual interconnectedness of professional responsibility and its structural and epistemic preconditions to be able to fulfil clinicians’ responsibility in a meaningful manner. The study also sheds light on the four relata of responsibility understood as a relational concept. The article closes with concrete suggestions for the ethically sound clinical implementation of ML-CDSS. (shrink)

Background The ethical governance of Artificial Intelligence (AI) in health care and public health continues to be an urgent issue for attention in policy, research, and practice. In this paper we report on central themes related to challenges and strategies for promoting ethics in research involving AI in global health, arising from the Global Forum on Bioethics in Research (GFBR), held in Cape Town, South Africa in November 2022. Methods The GFBR is an annual meeting organized by the World (...) Health Organization and supported by the Wellcome Trust, the US National Institutes of Health, the UK Medical Research Council (MRC) and the South African MRC. The forum aims to bring together ethicists, researchers, policymakers, research ethics committee members and other actors to engage with challenges and opportunities specifically related to research ethics. In 2022 the focus of the GFBR was “Ethics of AI in Global Health Research”. The forum consisted of 6 case study presentations, 16 governance presentations, and a series of small group and large group discussions. A total of 87 participants attended the forum from 31 countries around the world, representing disciplines of bioethics, AI, health policy, health professional practice, research funding, and bioinformatics. In this paper, we highlight central insights arising from GFBR 2022. Results We describe the significance of four thematic insights arising from the forum: (1) Appropriateness of building AI, (2) Transferability of AI systems, (3) Accountability for AI decision-making and outcomes, and (4) Individual consent. We then describe eight recommendations for governance leaders to enhance the ethical governance of AI in global health research, addressing issues such as AI impact assessments, environmental values, and fair partnerships. Conclusions The 2022 Global Forum on Bioethics in Research illustrated several innovations in ethical governance of AI for global health research, as well as several areas in need of urgent attention internationally. This summary is intended to inform international and domestic efforts to strengthen research ethics and support the evolution of governance leadership to meet the demands of AI in global health research. (shrink)

The central theme and core objective of this comprehensive resource for elementary teachers on climate change and children’s emotions and resiliency is supporting children’s understanding of and respect for the interconnectedness all life: human, animal, plant, and clean air, water, and soil. Its broad social/cultural perspective emphasizes that social and ecological justice are interrelated. Challenging elementary teachers to more explicitly address current environmental issues with students in their classrooms, the book presents a diverse set of topics from a variety (...) of perspectives. Coverage includes descriptions of environmental education pedagogies such as nature-based experiences and place-based studies; peace-education practices; children doing environmental activism; and teachers supporting children emotionally in times of climate disruption and tumult. The pedagogies described invite student engagement and action in the public sphere. Children are represented as ‘agents of change’ engaged in social and environmental issues and problems through their actions both local and global. (shrink)

Background: Demand for organisational ethics capacity is growing in health organisations, particularly among managers. The role of clinical ethicists in, and perspective on, organisational ethics has not been well described or documented in the literature. Objective: To describe clinical ethicists’ perspectives on organisational ethics issues in their hospitals, their institutional role in relation to organisational ethics, and their perceived effectiveness in helping to address organisational ethics issues. Design and Setting: Qualitative case study involving semi-structured interviews with 18 clinical (...) ethicists across 13 health organisations in Toronto, Canada. Results: From the clinical ethicists’ perspective, the most pressing organisational ethics issues in their organisations are: resource allocation, staff moral distress linked to the organisation’s moral climate, conflicts of interest, and clinical issues with a significant organisational dimension. Clinical ethicists were consulted in particular on issues related to staff moral distress and clinical issues with an organisational dimension. Some ethicists described being increasingly consulted on resource allocation, conflicts of interest, and other corporate decisions. Many clinical ethicists felt they lacked sufficient knowledge and understanding of organisational decision-making processes, training in organisational ethics, and access to organisational ethics tools to deal effectively with the increasing demand for organisational ethics support. Conclusion: Growing demand for organisational ethics expertise in healthcare institutions is reshaping the role of clinical ethicists. Effectiveness in organisational ethics entails a re-evaluation of clinical ethics training to include capacity building in organisational ethics and organisational decision-making processes as a complement to traditional clinical ethics education. (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)

This article critically examines the development and consensus outputs of the Concussion in Sport Group. We examine the six Consensus Statements between 2001 and 2023 to explore the challenges that the presence of contextual forces pose to the development of effective and ethically justifiable medical guidelines to manage situations involving brain-injured athletes. First, we discuss the implicit and explicit ethical framework and goals underlining the statements. Secondly, drawing on a relational account of athlete choice, we expound on the (...) limitations of the framework, concentrating on those resulting from a simplified understanding of athlete autonomy. Thirdly, we conclude by proposing a series of recommendations to improve concussion management protocols: (1) adopting a broader understanding of autonomy built upon relational accounts, beyond just the healthcare professional-athlete relationship; (2) further minimizing conflicts of interest that increase athletes’ vulnerability and hinder decision-making ability; (3) enhancing healthcare professional training to allow better adjustment of treatment plans to athletes’ contexts; and (4) promoting research on sociocultural elements affecting athletes’ vulnerability and autonomy. (shrink)

Ecological research and conservation practice frequently raise difficult and varied ethical questions for scientific investigators and managers, including duties to public welfare, nonhuman individuals (i.e., animals and plants), populations, and ecosystems. The field of environmental ethics has contributed much to the understanding of general duties and values to nature, but it has not developed the resources to address the diverse and often unique practical concerns of ecological researchers and managers in the field, lab, and conservation facility. The emerging field of (...) “ecological ethics” is a practical or scientific ethics that offers a superior approach to the ethical dilemmas of the ecologist and conservation manager. Even though ecological ethics necessarily draws from the principles and commitments of mainstream environmental ethics, it is normatively pluralistic, including as well the frameworks of animal, research, and professional ethics. It is also methodologically pragmatic, focused on the practical problems of researchers and managers and informed by these problems in turn. The ecological ethics model offers environmental scientists and practitioners a useful analytical tool for identifying, clarifying, and harmonizing values and positions in challenging ecological research and management situations. Just as bioethics provides a critical intellectual and problem-solving service to the biomedical community, ecological ethics can help inform and improve ethical decision making in the ecology and conservation communities. (shrink)

Background Non-invasive prenatal testing (NIPT), which can screen for aneuploidies such as trisomy 21, is being implemented in several public healthcare systems across Europe. Comprehensive communication and information have been highlighted in the literature as important elements in supporting women’s reproductive decision-making and addressing relevant ethical concerns such as routinisation. Countries such as England and France are adopting broadly similar implementation models, offering NIPT for pregnancies with high aneuploidy probability. However, we do not have a deeper understanding of how (...) professionals’ counselling values and practices may differ between these contexts. Methods In this paper, we explore how professionals in England and France support patient decision-making in the provision of NIPT and critically compare professional practices and values. We draw on data from semi-structured interviews with healthcare professionals. Results Both English and French professionals emphasised values relating to patient choice and consent. However, understandings and application of these values into the practice of NIPT provision differed. English interviewees placed a stronger emphasis on interpreting and describing the process of counselling patients and clinical care through a “principle” lens. Their focus was on non-directiveness, standardisation, and the healthcare professional as “decision-facilitator” for patients. French interviewees described their approach through a “procedural” lens. Their focus was on formal consent, information, and the healthcare professional as “information-giver”. Both English and French professionals indicated that insufficient resources were a key barrier in effectively translating their values into practice. Conclusion Our findings illustrate that supporting patient choice in the provision of NIPT may be held as an important value in common on a surface level, but can be understood and translated into practice in different ways. Our findings can guide further research and beneficially inform practice and policy around NIPT provision. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:Women, Ethics, and Inequality in US Healthcare: “To Count among the Living” by Aana Marie Vigen, and: New Feminist Christianity: Many Voices, Many Views ed. by Mary E. Hunt and Diann L. NeuKelly Denton-BorhaugWomen, Ethics, and Inequality in US Healthcare: “To Count among the Living” By Aana Marie Vigen NEW YORK: PALGRAVE MACMILLAN, 2011. 304 PP. $31.11New Feminist Christianity: Many Voices, Many Views Edited by Mary (...) E. Hunt and Diann L. Neu WOODSTOCK, VT: SKYLIGHT PATHS, 2010. 384 PP. $24.99In this age of the Supreme Court Hobby Lobby decision, which declared that corporation owners’ religious commitments could provide a basis for denial of their employees’ critical reproductive health insurance benefits (with particular impact on the lives of women), ethical investigation of medical sociology, theology, and the realities of women’s lives is more important than ever. Originally released in 2006, Aana Marie Vigen’s Women, Ethics, and Inequality in US Healthcare makes important headway through these complex waters. And for this volume in the Palgrave Macmillan Series on Black Religion / Womanist Thought / Social Justice, editors Dwight N. Hopkins [End Page 202] and Linda E. Thomas set forth the goal to “pioneer conceptual work and boundary-pushing effort engaging Black Religion or Womanist thought, and social justice” (xiv).Rereleased in paperback in 2011 with a new preface, Vigen’s updated health statistics reveal how racial-ethnic minorities “continue to be overrepresented among the ranks of the uninsured and/or of those living in poverty” (xliii). Her project is to better understand what enables and perpetuates this inequitable distribution and oppression, and to suggest methods of redress and reform. But in order to accomplish any of this, society in general and especially those with socioeconomic power—including administrative leaders in health care, medical providers, and ethicists—need to listen much more deeply to the stories of those who are most vulnerable and are being most negatively affected by current health care systems and practices. For Vigen, this meant a decision to focus on in-depth interviews with eight black and Latina women with breast cancer, in addition to six health care providers.With this method, Vigen pursues a very ambitious goal to, as she puts it, “begin a conversation among several distinct dialogue partners: medical sociology, biomedical ethics, ethnography, theology, and feminist social ethics” (5). She uses a “reflexive” practice, striving for openness to the new insights and ideas that emerged from this creative, multidisciplinary encounter. However, even before launching her interviews, her analysis of the process to seek approval from the Institutional Research Board illustrates the “clash of cultures” she would encounter, as she writes, “one cannot take for granted that others will share the view that women of color are able to speak truth in their own right and out of their own experiences—without comparison to others—about human personhood, dignity, and adequate healthcare quality” (107). It is to Vigen’s credit that she remained undeterred; if anything, the struggle she encountered with powerful leaders helped to confirm and focus the value of this work: not to tell every story, “but to tell a few with care and attention to detail” (108).Vigen’s ethnographical method makes it possible for her to illuminate and address not only stark inequities but also much subtler dynamics of racism combined with socioeconomic discrimination. Along the way, she illustrates a wide variety of experiences of oppression. In contrast to the experience of white patients, these female patients of color tended to be sent to the accounting/financing office before being allowed to see the doctor (144). Though white patients may express strong emotions in medical settings, some women of color felt pressured to reassure white doctors that they could be rational and not overly emotional (141). Socioeconomic and racial discrimination often reinforced one another in these settings. Perhaps most alarming, Vigen notes, the white care providers she interviewed seemed to be very unconscious of [End Page 203] their own racial identity and its role in medical care encounters (165). Her final chapter concludes with a series of immensely practical ethical mandates that would help alter these oppressive patterns. Clergy, students of ethics, and anyone... (shrink)

Background Respect is essential to providing high quality healthcare, particularly for groups that are historically marginalized and stigmatized. While ethical principles taught to health professionals focus on patient autonomy as the object of respect for persons, limited studies explore patients’ views of respect. The purpose of this study was to explore the perspectives of a multiculturally diverse group of low-income women living with HIV (WLH) regarding their experience of respect from their medical physicians. Methods We analyzed 57 semi-structured (...) interviews conducted at HIV case management sites in South Florida as part of a larger qualitative study that explored practices facilitating retention and adherence in care. Women were eligible to participate if they identified as African American (n = 28), Hispanic/Latina (n = 22), or Haitian (n = 7). They were asked to describe instances when they were treated with respect by their medical physicians. Interviews were conducted by a fluent research interviewer in either English, Spanish, or Haitian Creole, depending on participant’s language preference. Transcripts were translated, back-translated and reviewed in entirety for any statements or comments about “respect.” After independent coding by 3 investigators, we used a consensual thematic analysis approach to determine themes. Results Results from this study grouped into two overarching classifications: respect manifested in physicians’ orientation towards the patient (i.e., interpersonal behaviors in interactions) and respect in medical professionalism (i.e., clinic procedures and practices). Four main themes emerged regarding respect in provider’s orientation towards the patient: being treated as a person, treated as an equal, treated without blame or prejudice, and treated with concern/emotional support. Two main themes emerged regarding respect as evidenced in medical professionalism: physician availability and considerations of privacy. Conclusions Findings suggest a more robust conception of what ‘respect for persons’ entails in medical ethics for a diverse group of low-income women living with HIV. Findings have implications for broadening areas of focus of future bioethics education, training, and research to include components of interpersonal relationship development, communication, and clinic procedures. We suggest these areas of training may increase respectful medical care experiences and potentially serve to influence persistent and known social and structural determinants of health through provider interactions and health care delivery. (shrink)

Relationship and sex counseling are pivotal components of the “therapeutization of society,” which has been identified and widely examined as a key transformation of 21st-century modern Western societies. The particular understandings of gender and sexuality that circulate in those practices contribute to the wider everyday conceptions of intimate life and are thus important to investigate from a feminist perspective. Combining insights from studies on therapeutic cultures, research on intimate relationships, scholarship on postfeminism, and affect theory, this article (...) taps into the often ambivalent ways in which gender equality and sexual rights are articulated in relationship and sex counseling practices. My data are derived from an ethnographic investigation of relationship enhancement events in Finland. Equality was widely supported at these events, but there was no consensus regarding what desirable equality actually looked like. My analysis identifies several contradictory patterns in the data. First, there are statements to the effect that equality has “gone too far.” Second, many experts express tokenized critiques yet remain invested in depoliticizing views. Third, there are acts of resistance that embrace diversity and expand everyday understandings of gender and sexuality. I argue that these patterns constitute a postfeminist sensibility, thus complicating the belief that Nordic countries are exceptionally supportive of equality. (shrink)

Intellectual virtues are an integral part of adequate environmental virtue ethics; these virtues are distinct from moral virtues. Including intellectual virtues in environmental virtue ethics produces a more fine-grained account of the forces involved in environmental exploration, appreciation, and decision making than has been given to date. Intellectual virtues are character traits that regulate cognitive activity in support of the acquisition and application of knowledge. They are virtues because they further the human quest for knowledge and true belief; (...) possessing these traits improves us epistemically. Five intellectual virtues illustrate the nature and relevance of intellectual virtues to environmental ethics: thoroughness, temporal/structural sensitivity, flexibility, intellectual trust, and humility. While these virtues share many features of the moral virtues, there are differences between them that have practical implications and give sound reasons for considering these two types as distinct kinds. Intellectual virtues bear a structural relation to knowledge that moral virtues do not, and it is this epistemological stamp that sets them apart. Additionally, the two types of virtue can be possessed independently of one another. Ideally, intellectual virtues will combine with moral virtues such as respect, compassion, and humility to facilitate environmentally respectful behavior. The moral and intellectual virtues are thus importantly distinct and mutually reinforcing. Both should be present in a truly excellent human being, and both have a role to play in fully developed environmental virtue ethics. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Ideal of Shared Decision Making Between Physicians and PatientsDan W. Brock (bio)IntroductionShared treatment decision making, with its division of labor between physician and patient, is a common ideal in medical ethics for the physician-patient relationship.1 Most simply put, the physician's role is to use his or her training, knowledge, and experience to provide the patient with facts about the diagnosis and about the prognoses without treatment and with (...) alternative treatments. The patient's role in this division of labor is to provide the values—his or her own conception of the good—with which to evaluate these alternatives, and to select the one that is best for himself or herself. As a rough guide to practice, this is a reasonable conception; most of the time it is likely to produce sound treatment decisions. However, as an ideal it is too simplistic, and is subject to several challenges that I will explore in this paper.Some challenges relate to the physician's role. This facts/values division of labor seems to assume that the physician can and should provide the facts about treatment alternatives in a value-neutral form. But some have questioned whether the sciences on which medicine is based are, or can be, value free. Moreover, the concepts of health and disease, and of the normal and pathological, are held by many to be value laden. And even if it is possible for physicians to provide only value-neutral facts to the patient, should the physicians' role be restricted in this way?Other challenges that I will present in the paper are to the patient's role [End Page 28] as provider of the values for the evaluation of the different treatment alternatives. One defense of this role is based on the claim that physicians are not in a position to know reliably what is in a patient's best interests (Buchanan, forthcoming). I believe at least as influential—even if often not explicitly stated—is an extreme subjectivism about values that assumes that the patient's own ultimate values, which define his or her own conception of the good, are incorrigible. By incorrigible, I mean they cannot be mistaken. In the standard case in which treatment is pursued for the patient's benefit, this extreme subjectivism is thought to support the patient's values guiding treatment decision making and treatment. I will explore this incorrigibility claim and will argue that on each of the main philosophical conceptions of the good for persons it is indefensible and should not be the basis for shared treatment decision making.Underlying this view of the physician-patient division of labor are assumptions and beliefs about the nature and relation of facts and values, and science and ethics, that are largely the legacy of a logical positivism that has long since been rejected by most philosophers. It is time that these unstable foundations for our normative ideal of the physician-patient relation were finally removed and replaced with more defensible underpinnings.Two Models of the Physician-Patient RelationshipPositivists insisted on a relatively sharp distinction between descriptive or empirical claims and science, on the one hand, and evaluative claims and ethics, on the other.2 Descriptive statements and the claims of science were to be true or false according to whether they in fact correctly described and explained the world. By remaining properly descriptive or empirical, science could, at least in principle, be entirely value neutral or value free.In its more extreme versions, positivism held that ethical judgments lacked cognitive content, but were instead expressions of emotions or attitudes, and as such could be neither true nor false, correct or mistaken. Because no evaluative statements were held to be logically entailed by any descriptive or empirical statements, moral reasoning was thought to be properly understood not as reasoning but as attempts at nonrational persuasion.3 Many drew from this an extreme subjectivism in ethics along the lines of what I have called above the incorrigibility thesis—there is no meaningful sense in which an individual's ultimate values defining his or her own conception of the good life could be mistaken, false, or unfounded.These... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Rethinking Daoism as Activism:The Political Wisdom of Daoist Texts as a Response to the Contemporary Environmental CrisisLisa Indraccolo (bio)To propose a reading of Daoism as a form of social activism at first might sound almost paradoxical. This trend of thought is in fact well known for promoting, as a healthy, sustainable way of life for both the individual1 and the surrounding natural environment, what might actually seem the (...) exact opposite of social activism. The present discussion aims at showing that Daoism can actually be understood and practiced as a form of proactive social engagement, taking as a starting point Eric S. Nelson's recent work Daoism and Environmental Philosophy: Nourishing Life (2021), and in particular chapter 5, "Early Daoist biopolitics and a new Daoist political ecology" (pp. 100–118). As will be shown, it is a rather unique kind of social activism that differs from both science-based environmentalism and militant public activism. This article further problematizes certain reductionist tendencies that are still very much alive in the contemporary academic debate about and interpretations of early Daoism, and in particular of its political philosophy. This issue is particularly relevant when we proceed to address Daoist ecopolitics, and especially its applicability to the environmental crisis. From this perspective, Nelson convincingly persuades the reader of the potential and the contemporary relevance of certain pragmatic aspects, and in particular practices or "virtuous attitudes," theorized by early Daoist ecopolitical discourse in tackling environmental issues of global concern.Nelson's contribution addresses wuwei 無為, the well-known Daoist way of proactive non-action or "effortless action,"2 or, as Nelson persuasively interprets it, "attuned action,"3 "attuned responsiveness,"4 or "attuned, effortless, non-calculative unforced responsiveness,"5 thereby providing a substantial contribution to further refining the concept with an even more successful translation. Wuwei means acting without either being subjected to or exerting coercion, and in accordance or in "attunement" with the natural course of things. As Nelson suggests, such a way of acting and behaving could be systematically applied to radically rethink and revolutionize contemporary non-eco-friendly and eventually self-sabotaging, dysfunctional forms of human aggregation and interaction.In this most valuable enterprise, Nelson's book achieves two additional goals, touching upon two other critical and closely interconnected issues. First, Nelson draws attention to and provides substantial evidence to support the existence of a fairly coherent theoretical system as the basis of Daoist [End Page 781] political philosophy, with a focus on its political ecology, which has often been overlooked or neglected in favor of other apparently more appealing aspects of Daoist thinking. Nelson's analysis provides a fundamental contribution to a most necessary "demystification" of Daoist philosophy. By unveiling its substantially political underlying goals and agenda, his study thereby reconciles Daoist thought and brings it into a more coherent dialogue with the intellectual landscape of the Warring States period, during which we might assume that the two main received texts associated with this tradition, the Laozi 老子 and the Zhuangzi 莊子, started to assume the form in which they were eventually transmitted.Second, in doing so, Nelson's book contributes to the gradual ongoing process of "decolonization" of Chinese philosophy in a twofold way. It further invites considerations about certain latent "orientalistic" tendencies that are evidently still very much alive in the way in which Western scholarship approaches the study of early Chinese philosophy, and in preconceived ideas about certain texts and trends of thought and their imaginary conceptual boundaries, in which it still indulges at times. Moreover, Nelson proposes concrete ways in which ancient Daoist ideas and practices could be enacted in today's world to tackle the current ecological crisis by acting upon society in order to promote radical changes in people's attitude, not only toward the environment, but also toward each other, "therapeutically fostering a more appropriate ecological culture"6 and rethinking the very same concept of society and the principles that are its basis. Nelson shows the universality of the message of Daoist thought (and thereby, one might be tempted to say, contributes to substantiating the legitimacy of Chinese philosophy)7 and its relevance to the contemporary debate on climate and the environmental crisis. Such a... (shrink)

The study of biodiversity spans many disciplines and includes data pertaining to species distributions and abundances, genetic sequences, trait measurements, and ecological niches, complemented by information on collection and measurement protocols. A review of the current landscape of metadata standards and ontologies in biodiversity science suggests that existing standards such as the Darwin Core terminology are inadequate for describing biodiversity data in a semantically meaningful and computationally useful way. Existing ontologies, such as the Gene Ontology and others in the Open (...) Biological and Biomedical Ontologies (OBO) Foundry library, provide a semantic structure but lack many of the necessary terms to describe biodiversity data in all its dimensions. In this paper, we describe the motivation for and ongoing development of a new Biological Collections Ontology, the Environment Ontology, and the Population and Community Ontology. These ontologies share the aim of improving data aggregation and integration across the biodiversity domain and can be used to describe physical samples and sampling processes (for example, collection, extraction, and preservation techniques), as well as biodiversity observations that involve no physical sampling. Together they encompass studies of: 1) individual organisms, including voucher specimens from ecological studies and museum specimens, 2) bulk or environmental samples (e.g., gut contents, soil, water) that include DNA, other molecules, and potentially many organisms, especially microbes, and 3) survey-based ecological observations. We discuss how these ontologies can be applied to biodiversity use cases that span genetic, organismal, and ecosystem levels of organization. We argue that if adopted as a standard and rigorously applied and enriched by the biodiversity community, these ontologies would significantly reduce barriers to data discovery, integration, and exchange among biodiversity resources and researchers. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Both Interpersonal and Structural Efforts Are Necessary for Healthcare Professionals to Avoid Committing MicroaggressionsChidiogo Anyigbo (bio)I commend Lauren Freeman and Heather Stewart for acknowledging that the final chapter of Microaggressions and Medicine (2024), chapter 7, which provides practical guide for healthcare workers to avoid committing microaggressions, is a work in progress. The authors primarily focus on "strategies that can be implemented on the interpersonal and environmental levels (...) because this is where we can all immediately make the most impact to reduce microaggressions and their harmful consequences" (189). Presumably, readers of Microaggression and Medicine will by and large be healthcare workers: physicians, nurses, and allied health professionals working in direct patient care settings, and presumably these individuals pick up a book like Microaggression in Medicine to apply it to their own practice. Therefore, it may seem logical to act at the level that is closest to us as readers.The authors highlight seven strategies for reducing microaggressions in the healthcare space:• diversify employees• hire local health advocates, activists, and consultants to offer feedback on clinic design and practices• incorporate micro-cues into medical practices• foster medical humility• practice ethical listening• collaborate with patients as epistemic peers• increase awareness and education for colleagues and staffSome of these strategies occur at a systems level, like diversifying employees, hiring local health advocates, and creating staff educational awareness. Others are intended as steps for individuals to take during patient encounters. All of [End Page 152] these points, however, show how structural and systemic changes are important to address concurrently with taking individual steps. For example, if one makes interpersonal efforts to reduce or avoid microaggressions but is at the same time still operating within systems and structures that reinforce microaggressions, not only will harm continue to be done, but there is also a risk of burnout for the individual trying to make strides despite these harmful systems (as Hambrick and Tang Girdwood [2024] discuss). This may lead individuals to view their interpersonal and environmental efforts as futile because they do not lead to widespread reduction in microaggressions.For example, these structural and systemic strategies can start with institutional and organizational policies, for example, regarding how to respond to patients who harass healthcare professionals or expectations patients can have regarding the care they receive. Not only do patients experience microaggressions from healthcare workers, which is the focus of Freeman and Stewart's book, but healthcare workers can also experience microaggressions from patients (as Hambrick and Tang Girdwood elaborate). Hiring a diverse staff at all levels can certainly help foster a more inclusive environment, but it is not sufficient, and it also can lead to healthcare workers from historically underrepresented groups being the target of microaggressions from patients, their surrogate decision-makers, or their families. Institutional approaches to diversifying the healthcare workforce also need to consider how to best support a diverse healthcare workforce.The authors rightly point out that people of marginalized backgrounds often face a "minority tax" and that they are often the ones expected to do the uncompensated work of calling attention to and leading efforts to address microaggressions in their organization by educating colleagues and staff. As this happens, these more diverse staff may not feel the psychological safety or support needed to stay in the organization. The efforts to develop and maintain psychological safety are led by structural and systemic action, not solely individual herculean efforts. Education is not sufficient if there are no systems and policies in place to support and reinforce the desired behaviors.The concept of choice architecture is often used in business and behavioral economics to describe how to influence the conditions in which people make decisions to reduce bias, oftentimes creating default options that improve well being for many (Meder, Fleischhut, and Osman 2018). For example, this concept has been applied to improving healthy eating behaviors in workplaces (Rantala et al. 2024). There may be similar opportunities to explore how such efforts can be applied to create default action that does not rely on individual action and vigilance to address microaggressions. Choice architecture strategies for addressing microaggressions could perhaps expand the Institute for Healthcare Improvement (IHI) framework used for systems-based efforts to be... (shrink)

The descriptive moment in ethical reflection is helpfully informed by a careful consideration of what religious bodies have said about moral issues such as climate change. As a case study, this article identifies and interprets primary documents of The United Methodist Church (UMC) and its predecessor institutions, providing a detailed examination of the historical development of this denomination’s environmental witness statements. Methodism's long‐standing engagement with environmental ethics, out of which a concern for anthropogenic climate change incrementally emerged, includes significant institutional (...) policies and practices. The history of Methodist environmental witness evidences a creative, faithful response by a religious denomination learning to grapple with the overwhelming problem of climate change. Describing and interpreting this history enables religious ethicists to engage Methodist environmental witness as they develop constructive models for addressing this problem. (shrink)

Making research data readily accessible during a public health emergency can have profound effects on our response capabilities. The moral milieu of this data sharing has not yet been adequately explored. This article explores the foundation and nature of a duty, if any, that researchers have to share data, specifically in the context of public health emergencies. There are three notable reasons that stand in opposition to a duty to share one’s data, relating to: (i) data property and ownership, (ii) (...) just distribution of benefits and burdens and (iii) the contemporary ethos of science. We argue each reason can be successfully met with corresponding rationale in favour of data sharing. Further support for data sharing has been echoed in policies of health agencies, funding bodies and academic institutions; in documents on the ethical conduct of biomedical research; and in discussions on the nature of public health. From this, we ascertain that sharing data is the morally sound default position. This article then highlights the key roles reciprocity and solidarity play in supporting the practice of data sharing. We conclude with recommendations to regard public health research data as a common-pool resource in order to build a framework for stable data sharing management. (shrink)

BackgroundThe clinical introduction of non-invasive prenatal testing for fetal aneuploidies is currently transforming the landscape of prenatal screening in many countries. Since it is noninvasive, safe and allows the early detection of abnormalities, NIPT expanded rapidly and the test is currently commercially available in most of the world. As NIPT is being introduced globally, its clinical implementation should consider various challenges, including the role of the surrounding social and cultural contexts. We conducted a qualitative study with healthcare professionals in (...) Lebanon and Quebec as case studies, to highlight the relevance of cultural contexts and to explore the concerns that should be taken into account for an ethical implementation of NIPT.MethodsWe conducted semi-structured interviews with 20 healthcare professionals (HCPs), 10 from each country, practicing in the field of prenatal screening and follow up diagnostic testing, including obstetricians and gynecologists, nurses, medical geneticists and, genetic counselors. We aimed to 1) explore HCPs’ perceptions and views regarding issues raised by NIPT and 2) to shed light on ways in which the introduction of the same technology (NIPT) in two different contexts (Lebanon and Quebec) raises common and different challenges that are influenced by the cultural norms and legal policies in place.ResultsWe identified challenges to the ethical implementation of NIPT. Some are common to both contexts, including financial/economic, social, and organizational/ educational challenges. Others are specific to each context. For example, challenges for Lebanon include abortion policy and financial profit, and in Quebec challenges include lobbying by Disability rights associations and geographical access to NIPT.ConclusionsOur findings highlight the need to consider specific issues related to various cultural contexts when developing frameworks that can guide an ethically sound implementation of NIPT. Further, they show that healthcare professional education and training remain paramount in order to provide NIPT counseling in a way that supports pregnant women and couples’ choice. (shrink)