Among the important functions of the healthcare provider in providing quality care is the monitoring of the social environment of the patient. Although it is increasingly recognized that caring activity must include the whole patient and not merely the technical and pharmacological aspects of the patient's needs, the impact of the social environment upon the total health state has not been explored and debated to the extent that It might be.

In celebration of the fortieth anniversary of the publication of Beauchamp and Childress’s Principles of Biomedical Ethics, a review is undertaken to compare the lists of principles in various bioethical theories to determine the extent to which the various lists can be reconciled. Included are the single principle theories of utilitarianism, libertarianism, Hippocratism, and the theories of Pellegrino, Engelhardt, The Belmont Report, Beauchamp and Childress, Ross, Veatch, and Gert. We find theories all offering lists of principles numbering from one (...) to ten. Many of the differences can be reconciled, but some critical differences remain. (shrink)

Medical ethics changed dramatically in the past 30 years because physicians and humanists actively engaged each other in discussions that sometimes led to confrontation and controversy, but usually have improved the quality of medical decision-making. Before then medical ethics had been isolated for almost two centuries from the larger philosophical, social, and religious controversies of the time. There was, however, an earlier period where leaders in medicine and in the humanities worked closely together and both fields were richer for it. (...) This volume begins with the 18th century Scottish Enlightenment when professors of medicine such as John Gregory, Edward Percival, and the American, Benjamin Rush, were close friends of philosophers like David Hume, Adam Smith, and Thomas Reid. They continually exchanged views on matters of ethics with each other in print, at meetings of elite intellectual groups, and at the dinner table. Then something happened, physicians and humanists quit talking with each other. In searching for the causes of the collapse, this book identifies shifts in the social class of physicians, developments in medical science, and changes in the patterns of medical education. Only in the past three decades has the dialogue resumed as physicians turned to humanists for help just when humanists wanted their work to be relevant to real-life social problems. Again, the book asks why, finding answers in the shift from acute to chronic disease as the dominant pattern of illness, the social rights revolution of the 1960's, and the increasing dissonance between physician ethics and ethics outside medicine. The book tells the critical story of how the breakdown in communication between physicians and humanists occurred and how it was repaired when new developments in medicine together with a social revolution forced the leaders of these two fields to resume their dialogue. (shrink)

Assesses the ethical problems that doctors face every day and advocates a more universal code of medical ethics, one that draws on the traditions of religion and philosophy.

When a new, brain-based definition of death was proposed fifty years ago, no one realized that the issue would remain unresolved for so long. Recently, six new controversies have added to the debate: whether there is a right to refuse apnea testing, which set of criteria should be chosen to measure the death of the brain, how the problem of erroneous testing should be handled, whether any of the current criteria sets accurately measures the death of the brain, whether standard (...) criteria include measurements of all brain functions, and how minorities who reject whole-brain-based definitions should be accommodated. These controversies leave little hope of consensus on how to define death for social and public policy purposes. Rather, there is persistent disagreement among proponents of three major groups of definitions of death: whole-brain, cardiocirculatory or somatic, and higher-brain. Given the persistence and reasonableness of each of these groups of definitions, public policy should permit individuals and their valid surrogates to choose among them. (shrink)

In its October 2001 issue, this journal published a series of articles questioning the Whole-Brain-based definition of death. Much of the concern focused on whether somatic integration - a commonly understood basis for the whole-brain death view - can survive the brain's death. The present article accepts that there are insurmountable problems with whole-brain death views, but challenges the assumption that loss of somatic integration is the proper basis for pronouncing death. It examines three major themes. First, it accepts the (...) claim of the "disaggregators" that some behaviors traditionally associated with death can be unbundled, but argues that other behaviors (including organ procurement) must continue to be associated. Second, it rejects the claims of the "somaticists," that the integration of the body is critical, arguing instead for equating death with the irreversible loss of "embodied consciousness," that is, the loss of integration of bodily and mental function. Third, it defends higher-brain views against the charge that they are necessarily "mentalist," that is, that they equate death with losing some mental function such as consciousness or personhood. It argues, instead, for the integration of bodily and mental function as the critical feature of human life and that its irreversible loss constitutes death. (shrink)

And so the matter might be allowed to rest. But unfortunately, despite the prevailing consensus that there really isn't any issue any longer between the two types of logic, we should like in this paper to reopen the whole issue. Our justification for so doing is that, so far as we know, in most of the discussions of the nature of the difference between Aristotelian logic and mathematical logic there has not been too much attention paid to the metaphysical question (...) as to what precisely so-called logical "forms" may be said to be. Thus everyone --both Aristotelians and mathematical logicians--quite glibly use the term "formal logic." But we wonder if either the one party or the other has ever stopped long enough seriously to consider the fact that the actual ontological status that is ascribed to such forms is very different for the one tradition from what it is for the other. Indeed, we cannot help feeling that as soon as such metaphysical differences are clearly recognized, philosophers may well come to see that Aristotelian logic and mathematical logic are not "both 'logic' in the strictest sense of the word," nor do they "both have, vaguely speaking, the same subject matter.". (shrink)

No one really believes that literally all functions of the entire brain must be lost for an individual to be dead. A better definition of death involves a higher brain orientation.

Clinicians cannot obtain valid consent to treatment because they cannot guess which treatment option will serve a particular patient's best interests. These guesses could be made more accurately if patients were paired with providers who share their deep values.

Twelve contributors discuss critical issues affecting medical ethics. Topics include: the normative principles of medical ethics, concepts of health and disease, the physician-patient relationship, human experimentation, informed consent, genetics, ethical issues in organ transplantation, and moral.

After distinguishing two different meanings of the notion of a morality internal to medicine and considering a hypothetical case of a society that relied on its surgeons to eunuchize priest/cantors to permit them to play an important religious/cultural role, this paper examines three reasons why morality cannot be derived from reflection on the ends of the practice of medicine: (1) there exist many medical roles and these have different ends or purposes, (2) even within any given medical role, there exists (...) multiple, sometimes conflicting ends, and, most critically, (3) the ends of any practice such as medicine must come from outside the practice, that is, from the basic ends or purposes of human living. The paper concludes by considering whether these ends external to medicine are universally part of the moral reality or whether they are socially constructed. The paper argues that, even if various cultural accounts of the common, universal morality are socially constructed, they may, nevertheless, be reflections, however, imperfect, of a more universal common morality that should be thought of as real. Therefore, the morality of medicine must come from a more fundamental morality external to medicine. That external morality will be socially constructed, but may nevertheless reflect an underlying common morality. (shrink)

The celebration of thirty years of publication of The Journal of Medicine and Philosophy provides an opportunity to reflect on how medical ethics has evolved over that period. The reshaping of the field has occurred in no small part because of the impact of branches of philosophy other than ethics. These have included influences from Kantian theory of respect for persons, personal identity theory, philosophy of biology, linguistic analysis of the concepts of health and disease, personhood theory, epistemology, and political (...) philosophy. More critically, medicine itself has begun to be reshaped. The most fundamental restructuring of medicine is currently occurring - stemming, in part, from the application of contemporary philosophy of science to the medical field. There is no journal more central to these critical events of the past three decades than The Journal of Medicine and Philosophy. (shrink)

While twentieth-century medical ethics has focused on the duty of physicians to benefit their patients, the next century will see that duty challenged in three ways. First, we will increasingly recognize that it is unrealistic to expect physicians to be able to determine what will benefit their patients. Either they limit their attention to medical well-being when total well-being is the proper end of the patient or they strive for total well-being, which takes them beyond their expertise. Even within the (...) medical sphere, they have no basis for choosing among the proper medical goals for medicine. Also, there are many plausible strategies for relating predicted benefits to harms, and physicians cannot be expert in picking among these strategies. Second, increasingly plausible ethical systems recognize that in some cases, patient benefit must be sacrificed to protect patient rights including the right to the truth, to have promises kept, to have autonomy respected, and to not be killed. Third, ethics of the next century will increasingly recognize that some patient benefits must be sacrificed to fulfill duties to others - either the duty to serve the interests of others or other duties such as keeping promises, telling the truth, and, particularly, promoting justice. Physicians in the twenty-first century will be seen as having a new, more limited duty to assist the patient in pursuing the patient's understanding of the patient's interest within the constraints of deontological ethical principles and externally imposed duties to promote justice. The result will be a duty to be loyal to the consumer of health care with the recognition that often this will mean that the physician is not permitted to pursue the physician's understanding of the patient's well-being. (shrink)

The origins of professional ethical codes and oaths are explored. Their legitimacy and usefulness within the profession are questioned and an alternative ethical source is suggested. This source relies on a commonly shared, naturally knowable set of principles known as common morality.

This modern interpretation of Aristotelian ethics is ideally suited for undergraduate philosophy courses. It is also an engaging work for the expert and the beginner alike, offering a middle ground between existential and analytic ethics. Veatch argues for the existence of ethical knowledge, and he reasons that this knowledge is grounded in human nature. Yet he contends that the moral life is not merely one of following rules or recipes, nor is human well being something simple. Rather, the moral (...) life, which Veatch calls 'rational or intelligent living', is the life of practical wisdom where individual judgement of the particular and the contingent is paramount. Veatch's Rational Man offers a pluralistic understanding of human well being without lapsing into moral relativism. For those interested in morality and liberty, Rational Man offers fertile ground for developing an account of free and responsible persons. It has profoundly influenced the work of Den Uyl, Campbell, Machan, Miller, Mack, and many others. (shrink)

This book is a consideration of the differences between Aristotelian and symbolic logic (and the metaphysical assumptions they come packaged with) and the consequences these have for how we view the world. What Veatch propose is to try to exhibit with respect to several of the key logical tools and devices – propositions, inductive and deductive arguments, scientific and historical explanations, definitions, etc. – how these several instruments are differently conceived, both as to their natures and their functions, in (...) each of these respective logics. (shrink)

: Research by Siminoff and colleagues reveals that many lay people in Ohio classify legally living persons in irreversible coma or persistent vegetative state (PVS) as dead and that additional respondents, although classifying such patients as living, would be willing to procure organs from them. This paper analyzes possible implications of these findings for public policy. A majority would procure organs from those in irreversible coma or in PVS. Two strategies for legitimizing such procurement are suggested. One strategy would be (...) to make exceptions to the dead donor rule permitting procurement from those in PVS or at least those who are in irreversible coma while continuing to classify them as living. Another strategy would be to further amend the definition of death to classify one or both groups as deceased, thus permitting procurement without violation of the dead donor rule. Permitting exceptions to the dead donor rule would require substantial changes in law—such as authorizing procuring surgeons to end the lives of patients by means of organ procurement—and would weaken societal prohibitions on killing. The paper suggests that it would be easier and less controversial to further amend the definition of death to classify those in irreversible coma and PVS as dead. Incorporation of a conscience clause to permit those whose religious or philosophical convictions support whole-brain or cardiac-based death pronouncement would avoid violating their beliefs while causing no more than minimal social problems. The paper questions whether those who would support an exception to the dead donor rule in these cases and those would support a further amendment to the definition of death could reach agreement to adopt a public policy permitting organ procurement of those in irreversible coma or PVS when proper consent is obtained. (shrink)

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

The physician who upholds the Hippocratic oath is supposed to be loyal to his or her patients. This requires choosing only the therapy that the physician believes is best for the patient. However, knowing what is best requires randomized clinical trials. Thus, clinicians must be willing to recruit their patients to be assigned at random to one of two therapies in order to determine which is best based on the highest standards of pharmacological science.

The concept of care and a related ethical theory of care have emerged as increasingly important in biomedical ethics. This essay outlines a series of questions about the conceptualization of care and its place in ethical theory. First, it considers the possibility that care should be conceptualized as an alternative principle of right action; then as a virtue, a cluster of virtues, or as a synonym for virtue theory. The implications for various interpretations of the debate of the relation of (...) care and justice are then explored, suggesting three possible meanings for that contrast. Next, the possibility that care theorists are taking up the debate over the relation between principles and cases is considered. Finally, it is suggested that care theorists may be pressing for consideration of an entirely new question in moral theory: the assessment of the normative appropriateness of relationships. Issues needing to be addressed in an ethic of relationships are suggested. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:IntroductionRobert M. Veatch (bio)The Kennedy Institute of Ethics regularly sponsors intensive bioethics courses for physicians, nurses, and other health care professionals. While the basic course, held in June of each year, provides a general introduction to bioethics, advanced courses, which are often held in March, focus on more specific topics such as death and dying, justice and the allocation of resources, or theories and methods in bioethics. This (...) year the advanced course addressed one of the most sensitive and complex bioethical issues of our day: managed care. This issue of the Kennedy Institute of Ethics Journal includes revised versions of many of the papers from that meeting.As defined by one of the papers in this issue, managed care involves a system of health care delivery that manages resources, quality, and access associated with the delivery of health care. The key element of managed care is that, for the first time, managers—often from outside the health care professions—are intentionally controlling resources, and therefore controlling health care professional decisions that use those resources. The objective is not merely to eliminate utterly useless interventions—no one could plausibly object to that. Rather the target is also the elimination of inefficient and wasteful resource consumption. Increasingly, we recognize that many diagnostic tests and treatments offer, at best, a very marginal chance of doing the patient good. Some of these come at considerable cost. From the point of view of the rational organization of resources, no rational person would insist on receiving every last procedure that offers only a tiny chance to do a small amount of good at great cost. Managed care is designed to bring to consciousness and rationalize the decisions about which of these marginal, expensive benefits are worth pursuing.The problem is that any effort to eliminate any of the these expensive marginal services flies directly in the face of the Hippocratic ethic. Physicians and other clinicians traditionally are trained to believe that it is their moral duty to do what is best for the patient. Only now are we realizing that, taken literally, no rational person would want literally the best possible care, assuming that such care would include thousands of long-shot, expensive efforts to get the most modest of benefits at great cost. In a world of finite resources, rational people would certainly want very good medical care; they would want reasonable care. But they would also want some criteria of efficiency and fairness applied. The Hippocratic tradition has never addressed the problem of the difference between the best care and care that is of very high quality, but is chosen with an awareness that the best in medicine will necessarily come at the price of potentially serious [End Page vii] deprivation in other spheres of life. The ethics of managed care is fundamentally an exploration of how health care professionals can reconcile their traditional, if short-sighted and naive, commitment to doing what is best for their patients with increasing realism about the absurdity of pursuing every last possible increment of benefit.To the clinical health care professional, the issue raised most poignantly by managed care is whether the various health professions can still be practiced with integrity in a setting in which outsiders are charged with the rationalization and systematization of limits placed on excessive use of marginally beneficial resources. Edmund D. Pellegrino, a clinician and former Director of the Kennedy Institute, sets the tone for the course and for this issue of the Journal by making an appeal for the retention of the highest ethical standards of integrity for clinicians practicing in a managed care setting. He is unwilling to let standards be lowered in the process of systematizing the rational use of health care resources. The remaining papers in this issue respond to those pressures to change the nature of the clinical lay-professional relationship. Some of these presentations originated as panels designed to bring out varying points of view. The published form of the presentations, like the original oral remarks, are of different lengths. All have been edited by the presenters, some taking on the form of more finished papers, others still reflecting the less formal conversation of... (shrink)

The current definition of death used for donation after cardiac death relies on a determination of the irreversible cessation of the cardiac function. Although this criterion can be compatible with transplantation of most organs, it is not compatible with heart transplantation since heart transplants by definition involve the resuscitation of the supposedly "irreversibly" stopped heart. Subsequently, the definition of "irreversible" has been altered so as to permit heart transplantation in some circumstances, but this is unsatisfactory. There are three available strategies (...) for solving this "irreversibility problem": altering the definition of death so as to rely on circulatory irreversibility, rather than cardiac; defining death strictly on the basis of brain death (either whole-brain or more pragmatically some higher brain criteria); or redefining death in traditional terms and simultaneously legalizing some limited instances of medical killing to procure viable hearts. The first two strategies are the most ethically justifiable and practical. (shrink)

INTRODUCTION Five Questions of Ethics Medical ethics as a field presents a fundamental problem. As a branch of applied ethics, medical ethics becomes ...