: 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 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.

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.

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)

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.

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 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.

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)

This is a review of James Franklin's book, What Science Knows and How It Know It.

In The Healer's Power, Howard Brody placed the concept of power at the heart of medicine's moral discourse. Struck by the absence of “power” in the prevailing vocabulary of medical ethics, yet aware of peripheral allusions to power in the writings of some medical ethicists, he intuited the importance of power from the silence surrounding it. He formulated the problem of the healer's power and its responsible use as “the central ethical problem in medicine.” Through the prism of power (...) he refracted a wide range of ethical problems, from informed consent to truth-telling, from confidentiality to futility, from the physician's fantasies to the physician's virtues. At times this prism shed new light on old problems, enabling us to see from an unexpected angle the elements of which the problem was composed. At other times it exposed issues of ethical significance that had been neglected in the bioethics literature. (shrink)

This book (edited by Jonathan Y. Tsou, Jamie Shaw, and Carla Fehr) offers eighteen original historical and philosophical essays focused on values in science, scientific pluralism, and pragmatism. These themes have been central in the work of Matthew J. Brown, and the book frames these topics through an engagement with Brown’s broadly ranging work on values in science. The themes of this book are integrated and unified in the pragmatic and value-laden ideal of science defended by Professor Brown in (...) his fascinating 2020 book, Science and Moral Imagination. Brown's ideal of moral imagination prescribes that scientists should recognize the contingencies in their work as unforced choices, examine morally salient aspects of these decisions, recognize the various interests of relevant stakeholders, explore and construct alternative options, and exercise fair and warranted value judgments to guide those decisions. The interdisciplinary essays in this volume engage with different aspects of Brown's philosophical research on scientific values as well as his historical research on figures such as John Dewey and Paul K. Feyerabend. The international contributors to this volume include distinguished and familiar voices from the values in science literature (e.g., Kevin Elliott, Janet Kourany, and Don Howard) as well as newer voices. The resulting book showcases some of the latest innovative research being done on values, pluralism, and pragmatism, and it will be an important resource for researchers working on values in science. Specific topics addressed in the book include: moral imagination, inductive risk, epistemic priority, the value free ideal of science, values in the contexts of artificial intelligence and medicine, varieties of pluralism (e.g., epistemic, ethical, and cultural), and the structure of scientific communities. The book also features novel historical research on important figures in the traditions of pragmatism, pluralism, and values in science, such as John Dewey, John Stuart Mill, Paul Feyerabend, W. V. O. Quine, Ludwig Fleck, among others. The contributions to the volume represent a broad range of contemporary history and philosophy of science perspectives, which have guided Brown's own work, including socially relevant philosophy of science (SRPoiSE), history of philosophy of science (HOPOS), feminist philosophy of science, and philosophy of science in practice (SPSP). The book will be of interest to a broad audience of researchers working in philosophy of science, philosophy of medicine, history and philosophy of science, and science and technology studies. (shrink)

The American Philosophers contains papers by current leading philosophers and political theorists that explore the work of the major American philosophers from the colonial period to the present, from Jonathan Edwards to David Kaplan. Contains a philosophically and historically broad exploration of the major schools of American philosophy Examines both the pragmatists and the later Twentieth Century analytic philosophers, as well as such shapers of the political and philosophical American scene as Franklin, Jefferson, Madison, Emerson, and Jane Addams.

In challenging the prevailing paradigm for understanding how the human mind works, Patterns, Thinking, and Cognition is certain to stimulate fruitful debate.

While not paramount among Kant scholars, issues in the philosophy of mathematics have maintained a position of importance in writings about Kant’s philosophy, and recent years have witnessed a rejuvenation of interest and real progress in interpreting his views on the nature of mathematics. My hope here is to contribute to this recent progress by expanding upon the general tacks taken by Jaakko Hintikka concerning Kant’s writings on geometry.Let me begin by making a vile suggestion: Kant did not have a (...) philosophy of mathematics. When Kant was writing about mathematics, essentially he was reporting the views of others. The texts provide sufficient evidence to make this suggestion plausible. Generally, when Kant writes about mathematics in his mature works, he does so in order to illustrate or argue for a philosophical point. There are important references to mathematical method in the preface to the 1787 edition of Critique of Pure Reason; however, Kant’s purpose is to describe those basic features of a method that he intended to incorporate in his theory of philosophical method: ‘our new method of thought, namely, that we can know a priori of things only what we ourselves put into them.’ Indeed, Kant makes it clear in this preface that he thought there to be no extant problems to be solved in mathematical methodology; such was the state of the science, he thought. It was for this reason that Kant felt some confidence in borrowing from this method to improve the state of metaphysics; it is also for this reason that one should not expect to find Kant engaging in basic research in mathematical methodology. Similarly, the material on syntheticity added to the second edition Introduction to Critique of Pure Reason occurs in the context of a discussion of the syntheticity of metaphysical principles; that the propositions of both disciplines are synthetic a priori lends credence to the extrapolation of some features from the mathematical method for use in developing a metaphysics. Many writers find a philosophy of mathematics in the ‘Transcendental Aesthetic’; it is clear, however, that in this section his concern is to support his theory of the nature of space, time, and sensation. What is said about geometry, for example, is restricted to those of its features relevant to the subjectivity of space. The other major discussion of mathematics and its method is found in the section, ‘Doctrine of Method.’ Here we find Kant’s fullest account of the mathematical method and of constructions. It must be borne in mind, though, that his purpose is to argue against views that the proper methods of mathematics and metaphysics are identical, that the disciplines differ in subject matter alone. The result of the discussion is not a theory of mathematical method, but an account of the method proper to the philosopher.2 Kant simply is mentioning certain features of mathematical method sufficient to support the claim that the philosopher cannot incorporate it lock, stock, and barrel.’ In short, we do not find a systematic theory of mathematics or its method described by Kant in the first Critique, nor do we find discussions of mathematics other than in contexts where philosophical positions are being developed. This holds for Kant’s other works, too. (shrink)

Calibration, the use of a surrogate signal to standardize an instrument, is an important strategy for the establishment of the validity of an experimental result. In this paper, I present several examples, typical of physics experiments, that illustrate the adequacy of the surrogate. In addition, I discuss several episodes in which the question of calibration is both difficult to answer and of paramount importance. These episodes include early attempts to detect gravity waves, the question of the existence of a 17–keV (...) neutrino, and the question of the existence of a Fifth Force in gravity. I argue that in these more complex cases, the adequacy of calibration, in an extended sense, was both considered and established. (shrink)

Conventional medical ethics and the law draw a bright line distinguishing the permitted practice of withdrawing life-sustaining treatment from the forbidden practice of active euthanasia by means of a lethal injection. When clinicians justifiably withdraw life-sustaining treatment, they allow patients to die but do not cause, intend, or have moral responsibility for, the patient's death. In contrast, physicians unjustifiably kill patients whenever they intentionally administer a lethal dose of medication. We argue that the differential moral assessment of these two practices (...) is based on a series of moral fictions – motivated false beliefs that erroneously characterize withdrawing life-sustaining treatment in order to bring accepted end-of-life practices in line with the prevailing moral norm that doctors must never kill patients. When these moral fictions are exposed, it becomes apparent that conventional medical ethics relating to end-of-life decisions is radically mistaken. (shrink)

Kendler addresses three basic and interrelated questions that face all psychologists: What is the subject matter of psychology? What are the criteria for understanding psychological events? What ethical principles underlie the use of psychological knowledge? "[The book's] structure.... only hints at the literate and responsible handling of these current issues.... [it] would be enjoyable to use in teaching." --Psychological Report.

The first in a series that collects the "Sermon Series" by renowned African American theologian Howard Thurman, this volume on "Man and the Moral Struggle" and "The Message of the Prophets.".

The objective Bayesian view of proof (or logical probability, or evidential support) is explained and defended: that the relation of evidence to hypothesis (in legal trials, science etc) is a strictly logical one, comparable to deductive logic. This view is distinguished from the thesis, which had some popularity in law in the 1980s, that legal evidence ought to be evaluated using numerical probabilities and formulas. While numbers are not always useful, a central role is played in uncertain reasoning by the (...) ‘proportional syllogism’, or argument from frequencies, such as ‘nearly all aeroplane flights arrive safely, so my flight is very likely to arrive safely’. Such arguments raise the ‘problem of the reference class’, arising from the fact that an individual case may be a member of many different classes in which frequencies differ. For example, if 15 per cent of swans are black and 60 per cent of fauna in the zoo is black, what should I think about the likelihood of a swan in the zoo being black? The nature of the problem is explained, and legal cases where it arises are given. It is explained how recent work in data mining on the relevance of features for prediction provides a solution to the reference class problem. (shrink)

Presentism has received much scrutiny of late, yet little has been said of its definition. Many assume that it means simply that all that exists, exists at present. However, this definition will not do. It is defective in a multiplicity of ways. I consider and reject each of a number of intuitive ways in which to amend it. Each carries us a bit closer to our goal, but not until the end do we reach a definition that is wholly satisfactory. (...) The final definition has this remarkable feature: it has us posit abstracta of two kinds, namely, times and haecceities. (shrink)

Discussion about a dignified death has almost exclusively been applied to palliative care and people dying of cancer. As populations are getting older in the western world and living with chronic illnesses affecting their everyday lives, it is relevant to broaden the definition of palliative care to include other groups of people. The aim of the study was to explore the views on dignity at the end of life of 12 elderly people living in two nursing homes in Sweden. A (...) hermeneutic approach was used to interpret the material, which was gathered during semi-structured interviews. A total of 39 interviews were transcribed. The analysis revealed three themes: (1) the unrecognizable body; (2) fragility and dependency; and (3) inner strength and a sense of coherence. (shrink)

Journal of Political Philosophy, EarlyView.

We all have internal models (or maps) that represent the world. But all models/maps distort. Given the complexity of the world and the psychological limits to our representational ability, we must do with simplified models that work in those situations that are most important for us. But since our wants and situations differ, so will our models. When we encounter people with different models, we may try to convert them, but such conversion is unlikely if their models serve their wants (...) and situations. Once we give up on conversion, we may look for those mutually beneficial accommodations that are possible even when models differ. (shrink)

Readers interested in this paper will find it is reprinted as chapter nine of my book, Rationality, Relativism and Incommensurability.