"Unlike most photographs of Eads Bridge, which are taken from a distance, Quinta Scott's intimate photographic essay shows the subtleties of form and texture that give this structure its remarkable aesthetic impact. Howard Miller's text complements the photos, explaining the place of James Eads's unorthodox design in the history of American architecture and aesthetics. Miller also explains the bridge's place in local and national economic history, describes its innovative engineering, and brings to life its unique creator."--Jacket.

: The "difference position" holds that clinical research and therapeutic medical practice are sufficiently distinct activities to require different ethical rules and principles. The "similarity position" holds instead that clinical investigators ought to be bound by the same fundamental principles that govern therapeutic medicine—specifically, a duty to provide the optimal therapeutic benefit to each patient or subject. Some defenders of the similarity position defend it because of the overlap between the role of attending physician and the role of investigator in (...) a research trial. This overlap is maximal when the same physician occupies both roles with respect to a particular patient-subject. We address the ethical tensions inherent in that role conflict and argue that the tensions are real but manageable. The difference position provides a sound ethical framework within which to manage those tensions, while the similarity position is unsatisfactory because it seeks to deny the existence of the tensions. (shrink)

Some ethical issues facing contemporary medicine cannot be fully understood without addressing medicine's internal morality. Medicine as a profession is characterized by certain moral goals and morally acceptable means for achieving those goals. The list of appropriate goals and means allows some medical actions to be classified as clear violations of the internal morality, and others as borderline or controversial cases. Replies are available for common objections, including the superfluity of internal morality for ethical analysis, the argument that internal morality (...) is merely an apology for medicine's traditional power and authority, and the claim that there is no single, "core" internal morality. The value of addressing the internal morality of medicine may be illustrated by a detailed investigation of ethical issues posed by managed care. Managed care poses some fundamental challenges for medicine's internal morality, but also calls for thoughtful reflection and reconsideration of some traditionally held moral views on patient fidelity in particular. (shrink)

The leading ethical position on placebo-controlled clinical trials is that whenever proven effective treatment exists for a given condition, it is unethical to test a new treatment for that condition against placebo. Invoking the principle of clinical equipoise, opponents of placebo-controlled trials in the face of proven effective treatment argue that they (1) violate the therapeutic obligation of physicians to offer optimal medical care and (2) lack both scientific and clinical merit. We contend that both of these arguments are mistaken. (...) Clinical equipoise provides erroneous ethical guidance in the case of placebo-controlled trials, because it ignores the ethically relevant distinction between clinical trials and treatment in the context of clinical medicine and the methodological limitations of active-controlled trials. Placebo controls are ethically justifiable when they are supported by sound methodological considerations and their use does not expose research participants to excessive risks of harm. (shrink)

The COVID‐19 pandemic has infected millions around the world. Governments initially responded by requiring businesses to close and citizens to self‐isolate, as well as funding vaccine research and implementing a range of technologies to monitor and limit the spread of the disease. This article considers the use of smartphone metadata and Bluetooth applications for public health surveillance purposes in relation to COVID‐19. It undertakes ethical analysis of these measures, particularly in relation to collective moral responsibility, considering whether citizens ought, or (...) should be compelled, to comply with government measures. (shrink)

Biometric facial recognition is an artificial intelligence technology involving the automated comparison of facial features, used by law enforcement to identify unknown suspects from photographs and closed circuit television. Its capability is expanding rapidly in association with artificial intelligence and has great potential to solve crime. However, it also carries significant privacy and other ethical implications that require law and regulation. This article examines the rise of biometric facial recognition, current applications and legal developments, and conducts an ethical analysis of (...) the issues that arise. Ethical principles are applied to mediate the potential conflicts in relation to this information technology that arise between security, on the one hand, and individual privacy and autonomy, and democratic accountability, on the other. These can be used to support appropriate law and regulation for the technology as it continues to develop. (shrink)

In his own lifetime Confucius never attained real power and he died feeling that his life had been a failure; yet his teaching came to dominate the political and ritual life of China for thousands of years and to inspire many thinkers in the outside world. Howard Smith describes China in the sixth century B.C. and shows how its history of internal conflict, together with the cult of ancestor worship, gave rise to Confucius' central doctrines of order and (...) 'piety'. He relates how a few disciples kept this teaching alive after Confucius' death and how it came finally to be accepted throughout the huge Chinese empire as the basis for political, educational and ceremonial life. He describes also how Confucianism was slowly changed by the rival philosophies and religions with which it had to compete. This book is therefore not only a history of one of the world's greatest systems of belief but also a study of how such a system both creates and is created by the society in which it exists. -- From publisher's description. (shrink)

The doctrine of clinical equipoise is appealing because it appears to permit physicians to maintain their therapeutic obligation to offer optimal medical care to patients while conducting randomized controlled trials (RCTs). The appearance, however, is deceptive. In this article we argue that clinical equipoise is defective and incoherent in multiple ways. First, it conflates the sound methodological principle that RCTs should begin with an honest null hypothesis with the questionable ethical norm that participants in these trials should never be randomized (...) to an intervention known to be inferior to standard treatment. Second, the claim that RCTs preserve the therapeutic obligation of physicians misrepresents the patient-centered orientation of medical care. Third, the appeal to clinical equipoise as a basic principle of risk-benefit assessment for RCTs is incoherent. Finally, the difficulties with clinical equipoise cannot be resolved by viewing it as a presumptive principle subject to exceptions. In the final sections of the article, we elaborate on the non-exploitation framework for the ethics clinical research and indicate issues that warrant further inquiry. (shrink)

With breathtalung speed, traditional criminal prohibitions against assisted suicide have been declared unconstitutional in twelve states, including California and New York. This poses great promise and great peril. The promise is that competent terminally ill patients, as a compassionate measure of last resort, will have the option of putting an end to their suffering by physician-assisted suicide. More sigmficant, legally permitting this controversial option may be a catalyst for doctors, health care institutions, and society to improve the care of the (...) dying. PAS should be limited only to those relatively few competent patients who continue to suffer intolerably despite unrestrained efforts to palliate and who face a continued existence that they regard as worse than death. When dying patients know they will not be abandoned to miserable and pointless suffering if palliative care fails, they will be fortified to cope better with the process of dying.The immediate peril is that PAS will become a quick fix, available on demand to any patient diagnosed as terminally ill, thus bypassing palliative care and producing premature deaths. (shrink)

Forensic genomics now enables law enforcement agencies to undertake rapid and detailed analysis of suspect samples using a technique known as massively parallel sequencing (MPS), including information such as physical traits, biological ancestry, and medical conditions. This article discusses the implications of MPS and provides ethical analysis, drawing on the concept of joint rights applicable to genomic data, and the concept of collective moral responsibility (understood as joint moral responsibility) that are applicable to law enforcement investigations that utilize genomic data. (...) The widespread and unconstrained use of this technology without appropriate legal protections of individual moral rights and associated accountability mechanisms, could potentially not only involve violations of individual moral rights but also lead to an unacceptable shift in the balance of power between governments and the citizenry. We argue that in light of the rights of victims and the security benefits for society, there is a collective moral responsibility for individuals to submit their DNA to law enforcement and for MPS to be used where other, less invasive techniques are not effective. However, this application should be limited by legislation, including that any data obtained should be directly relevant to the investigation and should be destroyed at the conclusion of the investigation. (shrink)

A predominant ethical view holds that physician‐investigators should conduct their research with therapeutic intent. And since a physician offering a therapy wouldn't prescribe second‐rate treatments, the experimental intervention and the best proven therapy should appear equally effective. "Clinical equipoise" is necessary. But this perspective is flawed. The ethics of research and of therapy are fundamentally different, and clinical equipoise should be abandoned.

This book undertakes a multifaceted and integrated examination of biometric identification, including the current state of the technology, how it is being used, the key ethical issues, and the implications for law and regulation. The five chapters examine the main forms of contemporary biometrics–fingerprint recognition, facial recognition and DNA identification– as well the integration of biometric data with other forms of personal data, analyses key ethical concepts in play, including privacy, individual autonomy, collective responsibility, and joint ownership rights, and proposes (...) a raft of principles to guide the regulation of biometrics in liberal democracies. Biometric identification technology is developing rapidly and being implemented more widely, along with other forms of information technology. As products, services and communication moves online, digital identity and security is becoming more important. Biometric identification facilitates this transition. Citizens now use biometrics to access a smartphone or obtain a passport; law enforcement agencies use biometrics in association with CCTV to identify a terrorist in a crowd, or identify a suspect via their fingerprints or DNA; and companies use biometrics to identify their customers and employees. In some cases the use of biometrics is governed by law, in others the technology has developed and been implemented so quickly that, perhaps because it has been viewed as a valuable security enhancement, laws regulating its use have often not been updated to reflect new applications. However, the technology associated with biometrics raises significant ethical problems, including in relation to individual privacy, ownership of biometric data, dual use and, more generally, as is illustrated by the increasing use of biometrics in authoritarian states such as China, the potential for unregulated biometrics to undermine fundamental principles of liberal democracy. Resolving these ethical problems is a vital step towards more effective regulation. (shrink)

The main aim of this article is to describe central elements of, and the relationships among, three interrelated domains of inquiry. The first domain is Charles Peirce's semiotic theory which offers five concepts of special relevance to the other two domains: primary components of the triadic sign, including the object, representamen, and interpretant; the unceasing process of semiosis, or continuous growth of the developing sign; the three forms of inference, of which Peirce's notion of abduction is of special interest; the (...) element of surprise in experience, and the universal categories of Firstness, Secondness, and Thirdness that ground Peirce's overarching theory. The second domain incorporates the discipline of psychosemiotics, which is defined as the study of how we learn, understand, and use the signs of culture. The article outlines the nature and scope of psychosemiotics and emphasizes its grounding in Peircean semiotics, meaning‐making, and the five concepts listed above. The claim will be made that signs, semiosis, and meaning act through the seven signways outlined in the article and thereby bind the individual into the surrounding physical and cultural environments. The third domain is formal education, for which implications are presented as derived from Peircean theory and viewed through the psychosemiotic lens. In this perspective, all forms of education are semiotic processes grounded in signs and meaning‐making. Further, formal education consists of learning a wide variety of culturally‐valued signs by way of the seven signways and through processes that often differ from a technocratic, standards‐driven, accountability‐oriented approach to learning and instruction. (shrink)

A special report of The Hastings Center and the Association of American Medical Colleges addressed the ethical oversight of learning health systems, which seek to combine high‐quality patient care with routine data collection aimed at improving patient outcomes. The report contained two position papers, authored by a number of distinguished bioethicists, and several commentaries. The position papers urged two changes. First, they urged a rethinking of our approach to the regulation of human subjects research, so as to make it easier (...) in the future for learning health systems to function well. Second, they argued that the rethinking required dispensing with a strict distinction between research and therapy, which has been a major tenet of bioethics since the Belmont Report, which explicated basic ethical principles governing human subjects research. We fully support the objectives of the authors, and we agree that the learning health system is an important advance that serves patients well. Unnecessary regulatory burden ought not impede this progress. We disagree, however, that the best way to bring about these needed changes in the regulatory environment is to reject the basic distinction between research and treatment. Unfortunately, we find the arguments in favor of that strategy to be, in places, reminiscent of what we take to be basic conceptual errors that hampered the ethical understanding of human subjects research prior to adoption of the Belmont Report. To see why one need not reject the research‐treatment distinction in order to promote learning health systems, we first investigate in some detail the arguments offered for eliminating the distinction. We next turn to an issue not addressed by those authors, namely, the relationship between the physician or investigator and the patient or subject, to illustrate why the distinction is important and what is lost if it is jettisoned. (shrink)

The practice of voluntary physician‐assisted death as a last resort is compatible with doctors' duties to practice competently, to avoid harming patients unduly, to refrain from medical fraud, and to preserve patients' trust. It therefore does not violate physicians' professional integrity.

Technology regulation is one of the most important public policy issues facing society and governments at the present time, and further clarity could improve decision making in this complex and challenging area. Since the rise of the internet in the late 1990s, a number of approaches to technology regulation have been proposed, prompted by the associated changes in society, business and law that this development brought with it. However, over the past decade, the impact of technology has been profound and (...) the associated issues for government have extremely challenging, ranging across cyber security, artificial intelligence, and many other areas. To that end, this article introduces a Theory of Institutional Technology Actors and Norms (TITAN), a normatively informed and institutionally-based account of technology regulation. It focuses on the moral and legal (including regulatory) rights and responsibilities of the relevant actors and seeks to inform the development of regulation that is both fit for purpose, rights compliant and fair for all concerned. The account incorporates the perspectives of four key categories of groups in society: producers of technology, users of technology, government regulators, and normative policy shapers. (shrink)

Bioethics, Volume 35, Issue 8, Page 779-786, October 2021.

Background Nurses experienced intense ethical and moral challenges during the COVID-19 pandemic. Our 2020 qualitative parent study of frontline nurses’ experiences during the COVID-19 pandemic identified ethics as a cross-cutting theme with six subthemes: moral dilemmas, moral uncertainty, moral distress, moral injury, moral outrage, and moral courage. We re-analyzed ethics-related findings in light of refined definitions of ethics concepts. Research aim To analyze frontline U.S. nurses’ experiences of ethics during the COVID-19 pandemic. Research design Qualitative analysis using a directed content (...) methodology. Participants and research context The study included 43 nurses from three major metropolitan academic medical centers and one community hospital in the northeastern, mid-Atlantic, midwestern, and western United States. Ethical considerations Participant privacy and data confidentiality were addressed. Findings Moral dilemmas arose from many situations, most frequently related to balancing safety and patient care. Moral uncertainty commonly arose from lacking health information or evidence about options. Moral distress occurred when nurses knew the right thing to do, but were prevented from doing so, including with end-of-life issues. Moral injury (accompanied by suffering, shame, or guilt) occurred after doing, seeing, or experiencing wrongdoing, often involving authority figures. Nurses expressed moral outrage at events and people within and outside healthcare. Despite difficult ethical situations, some nurses exemplified moral courage, sometimes by resisting policies they perceived as preventing compassionate care, guided by thinking about what was best for patients. Discussion This content analysis of ethics-related subthemes revealed conceptual characteristics and clarified distinctions with corresponding exemplars. Conceptual clarity may inform responses and interventions to address ethical quandaries in nursing practice. Conclusions Ethics education in nursing must address the moral dilemmas of pandemics, disasters, and other crises. Nurses need time and resources to heal from trying to provide the best care when no ideal option was available. (shrink)

This article considers individual rights and fundamental tenets of the criminal justice system in the context of DNA evidence, in particular recent advancements in genomics that have significantly advanced law enforcement investigative capabilities in this area. It discusses a technique known as Investigative Genetic Genealogy (IGG) which utilizes genomic data held by commercial direct-to-consumer ancestry and health companies to investigate the identity of suspects linked to serious crimes. Using this technique, even if only a small proportion of the population (e.g. (...) 5%) has submitted genomic data to these companies, almost anyone in the population can be identified. We discuss this phenomenon in the context of the existing literature and arguments in relation to universal forensic DNA databases, as well as relevant recent developments in both liberal democracies and authoritarian states. We introduce the concept of a quasi-universal forensic DNA database and consider associated implications for the criminal justice system and society from the perspectives of privacy, the right not to self-incriminate, joint rights, and collective responsibility. (shrink)

Cosmetic surgery is a fast-growing medical practice. In 1997 surgeons in the United States performed the four most common cosmetic procedures443,728 times, an increase of 150% over the comparable total for 1992. Estimated total expenditures for cosmetic surgery range from $1 to $2 billion. As managed care cuts into physicians' income and autonomy, cosmetic surgery, which is not covered by health insurance, offers a financially attractive medical specialty.

A basic question of medical ethics is whether the norms governing medical practice should be understood as the application of principles and rules of the common morality to medicine or whether some of these norms are internal or proper to medicine. In this article we describe and defend an evolutionary perspective on the internal morality of medicine that is defined in terms of the goals of clinical medicine and a set of duties that constrain medical practice in pursuit of these (...) goals. This perspective is developed by means of a critical examination of the essentialist conception of the internal morality of medicine advocated by Edmund Pellegrino and the critique of internal morality approaches by Robert Veatch and Tom Beauchamp. (shrink)

While the effect of humanitarian intervention on the recurrence and intensity of armed conflict in a crisis zone has received significant scholarly attention, there has been comparatively less work on the negative externalities of introducing peacekeeping forces into conflict regions. This article demonstrates that large foreign forces create one such externality, namely a previously non-existent demand for human trafficking. Using Kosovo, Haiti, and Sierra Leone as case studies, we suggest that the injection of comparatively wealthy soldiers incentivizes the creation of (...) criminal networks by illicit actors. We theorize further that the magnitude of increase in trafficking should be directly proportional to the size of the foreign force, with larger forces producing larger increases. We find that both hypotheses hold with varying levels of confidence across our three case studies. Despite the benevolent intent of peacekeeping missions, the possibility that they may contribute to human trafficking for the purpose of sexual exploitation runs counter to the spirit of such interventions. This is especially problematic given that trafficking rings, once established, may be adapted to provide weapons and narcotics, thereby planting the seed of further destabilization. (shrink)

Background Unit-based critical care nurse leaders (UBCCNL) play a role in exemplifying ethical leadership, addressing moral distress, and mitigating contributing factors to moral distress on their units. Despite several studies examining the experience of moral distress by bedside nurses, knowledge is limited regarding the UBCCNL’s experience. Research aim The aim of this study was to gain a deeper understanding of the lived experiences of Alabama UBCCNLs regarding how they experience, cope with, and address moral distress. Research design A qualitative descriptive (...) design and inductive thematic analysis guided the investigation. A screening and demographics questionnaire and a semi-structured interview protocol were the tools of data collection. Participant and research context Data were collected from 10 UBCCNLs from seven hospitals across the state of Alabama from February to July 2023. Ethical considerations This study was approved by the Institutional Review Board at the University of Alabama in Huntsville. Informed consent was obtained from participants prior to data collection. Findings UBCCNLs experience moral distress frequently due to a variety of systemic and organizational barriers. Feelings of powerlessness tended to precipitate moral distress among UBCCNLs. Despite moral distress resulting in increased advocacy and empathy, UBCCNLs may experience a variety of negative responses resulting from moral distress. UBCCNLs may utilize internal and external mechanisms to cope with and address moral distress. Conclusions The UBCCNL’s experience of moral distress is not dissimilar from bedside staff; albeit, moral distress does occur as a result of the responsibilities of leadership and the associated systemic barriers that UBCCNLs are privier to. When organizations allocate resources for addressing moral distress, they should be convenient to leaders and staff. The UBCCNL perspective should be considered in the development of future moral distress measurement tools and interventions. Future research exploring the relationship between empathy and moral distress among nurse leaders is needed. (shrink)

Moral distress (MD) is well-documented within the nursing literature and occurs when constraints prevent a correct course of action from being implemented. The measured frequency of MD has increased among nurses over recent years, especially since the COVID-19 Pandemic. MD is less understood among nurse leaders than other populations of nurses. A qualitative systematic review was conducted with the aim to synthesize the experiences of MD among nurse leaders. This review involved a search of three databases (Medline, CINAHL, and APA (...) PsychINFO) which resulted in the retrieval of 303 articles. PRISMA review criteria guided authors during the article review and selection process. Following the review, six articles were identified meeting review criteria and quality was assessed using the Critical Appraisal Skills Programme (CASP) Checklist for qualitative studies. No ethical review was required for this systematic review. The six studies included in this review originated from the United States, Brazil, Turkey, and Iran. Leadership roles ranged from unit-based leadership to executive leadership. Assigned quality scores based upon CASP criteria ranged from 6 to 9 (moderate to high quality). Three analytical themes emerged from the synthesis: (1) moral distress is consuming; (2) constrained by the system; and (3) adapt to overcome. The unique contributors of MD among nurse leaders include the leadership role itself and challenges navigating moral situations as they arise. The nurse leader perspective should be considered in the development of future MD interventions. (shrink)

While the effect of humanitarian intervention on the recurrence and intensity of armed conflict in a crisis zone has received significant scholarly attention, there has been comparatively less work on the negative externalities of introducing peacekeeping forces into conflict regions. This article demonstrates that large foreign forces create one such externality, namely a previously non-existent demand for human trafficking. Using Kosovo, Haiti, and Sierra Leone as case studies, we suggest that the injection of comparatively wealthy soldiers incentivizes the creation of (...) criminal networks by illicit actors. We theorize further that the magnitude of increase in trafficking should be directly proportional to the size of the foreign force, with larger forces producing larger increases. We find that both hypotheses hold with varying levels of confidence across our three case studies. Despite the benevolent intent of peacekeeping missions, the possibility that they may contribute to human trafficking for the purpose of sexual exploitation runs counter to the spirit of such interventions. This is especially problematic given that trafficking rings, once established, may be adapted to provide weapons and narcotics, thereby planting the seed of further destabilization. (shrink)

*The opinions expressed are the views of the author and do not necessarily reflect the policy of the National Institutes of Health, the Public Health Service, or the U.S. Department of Health and Human Services.