Medical Ethics

Fetal reduction is the practice of reducing the number of fetuses in a multiple pregnancy, such as quadruplets, to a twin or singleton pregnancy. Use of assisted reproductive technologies increases the likelihood of multiple pregnancies, and many fetal reductions are done after in vitro fertilisation and embryo transfer, either because of social or health-related reasons. In this paper, I apply Joe Horton’s all or nothing problem to the ethics of fetal reduction in the case of a twin pregnancy. I argue (...) that in the case of a twin pregnancy, there are two intuitively plausible claims: (1) abortion is morally permissible, and (2) it is morally wrong to abort just one of the fetuses. But since we should choose morally permissible acts rather than impermissible ones, the two claims lead to another highly implausible claim: the woman ought to abort both fetuses rather than only one. Yet, this does not seem right. A plausible moral theory cannot advocate such a pro-death view. Or can it? I suggest ways to solve this problem and draw implications for each solution. (shrink)

No concept is more important for clear thinking about medical ethics than the concept of well-being or (what I take to be the same thing) the concept of what’s good for a person. Yet for a variety of reasons medical ethicists have generally had little to say about this notion. Medical ethics education, and bioethics more generally, would be better if people learned to think about welfare in a more substantial and structured way. Philosophers would typically approach such a problem (...) by teaching theories of well-being, in particular the “big three”: hedonism, desire satisfactionism, and objective list theories. I argue, however, that these theories are not helpful in the context of practical ethics. I develop an alternative approach to thinking about welfare in practical ethical contexts. It is philosophically informed yet avoids discussion of the “big three” theories. I call it the “theory- without-theories” approach. It has two elements. First is a focus on examining important and relatively uncontroversial constituents of welfare. These elements can be introduced and their nature questioned and probed without invoking general theories. The second key element is a framework for thinking about choice in relation to welfare, a framework that I refer to as “the mild objectivity framework.” I aim to convince readers, first, that the standard philosophical approach will not work in the practical context, and second, that the theory-without- theories approach will. (shrink)

When talking about personal identity in the context of medical ethics, ethicists tend to borrow haphazardly from different philosophical notions of personal identity, or to abjure these abstract metaphysical concerns as having nothing to do with practical questions in medical ethics. In fact, part of the moral authority for respecting a patient’s self-regarding decisions can only be made sense of if we make certain assumptions that are central to a particular, psychological picture of personal identity, namely, that patients will remain (...) psychologically connected to a certain degree with their future selves. I draw this out, show problems with approaches in medical ethics based on alternate theories of personal identity that do not recognise this, and explore some important implications. (shrink)

A clear and provocative introduction to the ethics of COVID-19, suitable for university-level students, academics, and policymakers, as well as the general reader. It is also an original contribution to the emerging literature on this important topic. The author has made it available Open Access, so that it can be downloaded and read for free by all those who are interested in these issues. Key features include: -/- A neat organisation of the ethical issues raised by the pandemic. An exploration (...) of the many complex interconnections between these issues. A succinct case for a continued lockdown until we develop a vaccine. An original account of the Deep Moral Problem of the Pandemic, and a Revolutionary Argument for how we should change society post-pandemic. References to, and engagement with, many of the best writings on the pandemic so far (both in popular media and academic journals). (shrink)

In this chapter, we consider ethical and philosophical aspects of trust in the practice of medicine. We focus on trust within the patient-physician relationship, trust and professionalism, and trust in Western (allopathic) institutions of medicine and medical research. Philosophical approaches to trust contain important insights into medicine as an ethical and social practice. In what follows we explain several philosophical approaches and discuss their strengths and weaknesses in this context. We also highlight some relevant empirical work in the section on (...) trust in the institutions of medicine. It is hoped that the approaches discussed here can be extended to nursing and other topics in the philosophy of medicine. (shrink)

Lippert-Rasmussen and Petersen discuss my ‘Moral case for legal age change’ in their article ‘Age change, official age and fairness in health’. They argue that in important healthcare settings (such as distributing vital organs for dying patients), the state should treat people on the basis of their chronological age because chronological age is a better proxy for what matters from the point of view of justice than adjusted official age. While adjusted legal age should not be used in deciding who (...) gets scarce vital organs, I remind the readers that using chronological age as a proxy is problematic as well. Using age as a proxy could give wrong results and it is better, if possible, for states to use the vital information directly than use age as a proxy. (shrink)

We can say that it is necessary for every human being to walk towards the comprehension of the contingent and limited reality of the human person, starting with those whose work involves dealing with patients, as well as those who dedicate themselves to bioethical reflection, and even the patients themselves. In this way, at the time when these people face a situation of pain and suffering, they will be able to assume it with integrity and strength, always choosing to protect (...) the valuable gift of human life, and not simply looking for it. to make the pain disappear as it may, tearing it up at the root, often ending up with a human life, be it at the moment of conception, as an embryo, with disabilities, sick or aging. -/- Podemos decir que es necesario que todo ser humano camine hacia la comprensión de la realidad contingente y limitada de la persona humana, empezando por aquellos cuyo trabajo involucra el trato con pacientes, así como quienes se dedican a la reflexión bioética, e incluso los mismos pacientes. De esta manera, en el momento en que estas personas se enfrenten a una situación de dolor y sufrimiento, podrán asumirla con entere-za y fortaleza, optando siempre por proteger el valioso don de la vida humana, y no simplemente buscando hacer desaparecer el dolor a como dé lugar, arrancándolo de raíz, muchas veces terminando con una vida huma-na, sea en el momento de la concepción, como embrión, con discapacidades, enferma o envejecida. (shrink)

Medical ghostwriting is the practice in which pharmaceutical companies engage an outside writer to draft a manuscript submitted for publication in the names of “honorary authors,” typically academic key opinion leaders. Using newly-posted documents from paroxetine litigation, we show how the use of ghostwriters and key opinion leaders contributed to the publication of a medical journal article containing manipulated outcome data to favor the proprietary medication. The article was ghostwritten and managed by SmithKline Beecham, now GlaxoSmithKline (GSK) and Scientific Therapeutics (...) Information, Inc. without acknowledging their contribution in the published article. The named authors with financial ties to GSK, had little or no direct involvement in the paroxetine 352 bipolar trial results and most had not reviewed any of the manuscript drafts. The manuscript was originally rejected by peer review; however, its ultimate acceptance to the American Journal of Psychiatry was facilitated by the journal editor who also had financial ties to GSK. Thus, GSK was able to take an under-powered and non-informative trial with negative results and present it as a positive marketing vehicle for off-label promotion of paroxetine for bipolar depression. In addition to the commercial spin of paroxetine efficacy, important protocol-designated safety data were unreported that may have shown paroxetine to produce potentially harmful adverse events. (shrink)

In a recent publication Tom Douglas and Katrien Devolder have proposed a new account of genetic parenthood, building on the work of Heidi Mertes. Douglas and Devolder’s account aims to solve, among other things, the question of who are the genetic parents of an individual created through somatic cell nuclear transfer (i.e. cloning): (a) the nuclear DNA provider or (b) the progenitors of the nuclear DNA provider. Such a question cannot be answered by simply appealing to the folk account of (...) genetic parenthood, according to which the genetic parents of an individual are those individuals who produced the egg and sperm, respectively, which fused to create the embryo. It cannot be so as in cloning there is no fertilization as such. In this article I critically examine Douglas and Devolder’s new account of genetic parenthood and demonstrate that it is vulnerable to counterexamples that exploit the lack of a condition specifying that genetic parents should cause a child’s coming into existence. (shrink)

In my article "Even if the fetus is not a person, abortion is immoral: The impairment argument" (this journal), I defended what I called “The impairment argument” which purports to show that abortion is immoral. Bruce Blackshaw (2019) has argued that my argument fails on three accounts. In this article, I respond to his criticisms.

Janet Malek (91–102, 2019) argues that a “clinical ethics consultant’s religious worldview has no place in developing ethical recommendations or communicating about them with patients, surrogates, and clinicians.” She offers five types of arguments in support of this thesis: arguments from consensus, clarity, availability, consistency, and autonomy. This essay shows that there are serious problems for each of Malek’s arguments. None of them is sufficient to motivate her thesis. Thus, if it is true that the religious worldview of clinical ethics (...) consultants should play no role whatsoever in their work as consultants, this claim will need to be defended on some other ground. (shrink)

In ’Abortion and deprivation: a reply to Marquis’, Anna Christensen contends that Don Marquis’ influential ’future like ours’ argument for the immorality of abortion faces a significant challenge from the Epicurean claim that human beings cannot be harmed by their death. If deprivation requires a subject, then abortion cannot deprive a fetus of a future of value, as no individual exists to be deprived once death has occurred. However, the Epicurean account also implies that the wrongness of murder is also (...) not grounded in the badness of death, which is strongly counterintuitive. There is an alternative: we can save our intuitions by adopting a more moderate Epicurean account such as that proposed by David Hershenov, who grounds the wrongness of killing in the prevention of the benefit of further good life rather than in the badness of death. Hershenov’s account, however, is equally applicable to Marquis’ argument: abortion similarly prevents a fetus from enjoying the benefit of a future like ours. Consequently, we conclude that Christensen’s criticism of Marquis’ argument fails to undermine his reasoning. (shrink)

Jake Greenblum and Ryan K Hubbard argue that physicians, nurses, clinical ethicists and ethics committee members should not cite religious considerations when helping patients (or their proxies) make medical decisions. They provide two arguments for this position: The Public Reason Argument and the Fiduciary Argument. In this essay, I show that the Public Reason Argument fails. Greenblum and Hubbard may provide good reason to think that physicians should not invoke their own religious commitments as reasons for a particular medical decision. (...) But they fail to show that it is wrong for physicians to cite the patient’s own religious commitments as reasons for a particular decision. As such, if Greenblum and Hubbard’s thesis is to survive, the Fiduciary Argument (or some unmentioned argument) will have to do the bulk of the work. (shrink)

Insufficient vaccination coverage is an important public health problem in many countries, since it leads to the loss of herd protection and the resurgence of previously exterminated diseases. However, policies of mandatory childhood vaccination capable of raising vaccination rates continue to be controversial. In this article I review the arguments for mandatory childhood vaccination, setting out the strongest teleological argument in favour, and then critically examining the two strongest potential objections: paternalism and the parental prerogative. I argue that the challenge (...) of paternalism fails because it confuses the identities of those subject to restricted liberty and those who autonomously dissent, and because non-vaccination imposes risks on others. I argue that the challenge of a parental prerogative fails because it cannot be intuitively or theoretically supported in a form that would make it permissible to impose risks on others. I conclude that in lieu of further and more plausible objections at least some policies of mandatory childhood vaccination are morally permissible. (shrink)

The “Embryo Rescue Case” (ERC) refers to a thought experiment that is used to argue against the view that embryos have a right to life (i.e. are persons). I will argue that cognitive science undermines the intuition elicited by the ERC; I will show that whether or not embryos have a right to life, our mental tools will make it very difficult to believe that embryos have said right. This suggests that the intuition elicited by the ERC is not truth (...) indicative. The upshot of this is that we have an undercutting defeater for our intuition that embryos do not have a right to life. (shrink)

Although McMillan recognizes that moral theory has its place, he suggests that by setting bioethics up as a discipline whose predominant issues are to do with theory, not only are students insulated from the broadness of its scope and the diversity of its methods, but the subject comes across as largely inaccessible to those without some formal train- ing in normative ethics and of limited practical signifi- cance to those dealing with concrete issues.

Some theorists argue that moral bioenhancement ought to be compulsory. I take this argument one step further, arguing that if moral bioenhancement ought to be compulsory, then its administration ought to be covert rather than overt. This is to say that it is morally preferable for compulsory moral bioenhancement to be administered without the recipients knowing that they are receiving the enhancement. My argument for this is that if moral bioenhancement ought to be compulsory, then its administration is a matter (...) of public health, and for this reason should be governed by public health ethics. I argue that the covert administration of a compulsory moral bioenhancement program better conforms to public health ethics than does an overt compulsory program. In particular, a covert compulsory program promotes values such as liberty, utility, equality, and autonomy better than an overt program does. Thus, a covert compulsory moral bioenhancement program is morally preferable to an overt moral bioenhancement program. (shrink)

One of the best-known principles of halakha is that Shabbat is violated to save a life. Who does this saving and how do we know that a life is in danger? What categories of illness violate Shabbat and who decides? A historical-sociological analysis of the roles played by Jew, non-Jew, and physician according to the approach of “medical cosmology” can help us understand the differences in the approach of the Shulchan Aruch compared to later decisors (e.g., the Mishnah Berurah). Such (...) differences illuminate how premodern medical triage coexisted with a different halakhic understanding than that of the biomedical age. (shrink)

In contemporary bioethics, the autonomy of the patient has assumed considerable importance. Progressing from a more limited notion of informed consent, shared decision making calls upon patients to voice the desires and preferences of their authentic self, engaging in choice among alternatives as a way to exercise deeply held values. One influential opinion in Jewish bioethics holds that Jewish law, in contradistinction to secular bioethics, limits the patient's exercise of autonomy only in those instances in which treatment choices are sensitive (...) to preferences. Here, we analyze a discussion in the Mishna, a foundational text of rabbinic Judaism, regarding patient autonomy in the setting of religiously mandated fasting, and commentaries in the Babylonian and Palestinian Talmuds, finding both a more expansive notion of such autonomy and a potential metaphysical grounding for it in the importance of patient self-knowledge. (shrink)

Physicians in Islamic countries might be requested to participate in the Islamic legal code of qiṣāṣ, in which the victim or family has the right to an eye-for-an-eye retaliation. Qiṣāṣ is only used as a punishment in the case of murder or intentional physical injury. In situations such as throwing acid, the national legal system of some Islamic countries asks for assistance from physicians, because the punishment should be identical to the crime. The perpetrator could not be punished without a (...) physician’s participation, because there is no way to guarantee that the sentence would be carried out without inflicting more injury than the initial victim had suffered. By examining two cases of acid throwing, this paper discusses issues related to physicians’ participation in qiṣāṣ from the perspective of medical ethics and Islamic Shari’a law. From the standpoint of medical ethics, physicians’ participation in qiṣāṣ is not appropriate. First, qiṣāṣ is in sharp contrast to the Hippocratic Oath and other codes of medical ethics. Second, by physicians’ participation in qiṣāṣ, medical practices are being used improperly to carry out government mandates. Third, physician participation in activities that cause intentional harm to people destroys the trust between patients and physicians and may adversely affect the patient–physician relationship more generally. From the standpoint of Shari’a, there is no consensus among Muslim scholars whether qiṣāṣ should be performed on every occasion. We argue that disallowing physician involvement in qiṣāṣ is necessary from the perspectives of both medical ethics and Shari’a law. (shrink)

Human eggs for basic, fertility and stem-cell research are in short supply. Many experiments that require their use cannot be carried out at present, and, therefore, the benefits that could emerge from these are either delayed or never materialise. This state of affairs is problematic for scientists and patients worldwide, and it is a matter that needs our attention. Recent advances in chimera research have opened the possibility of creating human/non-human animal chimeras intended for human gamete production (chimeras-IHGP). In this (...) paper, I examine four arguments against the creation of such chimeras and prove that all of them are found wanting. I conclude by showing that there is a strong moral reason for scientists to pursue this research avenue. (shrink)

In 2015 the United Kingdom (UK) became the first nation to legalize egg and zygotic nuclear transfer procedures using mitochondrial replacement techniques (MRTs) to prevent the maternal transmission of serious mitochondrial DNA diseases to offspring. These techniques are a form of human germline genetic modification and can happen intentionally if female embryos are selected during the MRT clinical process, either through sperm selection or preimplantation genetic diagnosis (PGD). In the same year, an MRT was performed by a United States (U.S.)-based (...) physician team. This experiment involved a cross-border effort: the MRT procedure per se was carried out in the US, and the embryo transfer in Mexico. The authors examine the ethics of MRTs from the standpoint of genetic relatedness and gender implications, in places that lack adequate laws and regulation regarding assisted reproduction. Then, we briefly examine whether MRTs can be justified as a reproductive option in the US and Mexico, after reassessing their legalization in the UK. We contend that morally inadequate and ineffective regulations regarding egg donation, PGD, and germline genetic modifications jeopardize the ethical acceptability of the implementation of MRTs, suggesting that MRTs are currently difficult to justify in the US and Mexico. In addition to relevant regulation, the initiation and appropriate use of MRTs in a country require a child-centered follow-up policy and more evidence for its safety. (shrink)

Much of the discussion surrounding the ethics of abortion has centered around the notion of personhood. This is because many philosophers hold that the morality of abortion is contingent on whether the fetus is a person - though, of course, some famous philosophers have rejected this thesis (e.g. Judith Thomson and Don Marquis). In this article, I construct a novel argument for the immorality of abortion based on the notion of impairment. This argument does not assume that the fetus is (...) a person - indeed, I concede (for the sake of argument) that the fetus is not a person - and hence the morality of abortion is not contingent on whether the fetus is a person. I finish by answering a plethora of objections to my argument, concluding that none of them are successful. (shrink)

A review of the new Czech-language textbook of medical ethics. I point out its multiple flaws, especially the insufficient grounding in normative theory and a bias towards the Catholic moral teachings.

Lawrence Nelson (2018) criticizes conscientious objection (CO) to abortion statutes as far as they permit health care providers to escape criminal liability for what would otherwise be the legally wrongful taking of a pregnant woman’s life by refusing treatment (i.e. abortion). His key argument refers to the U.S. Supreme Court judgment (Roe v. Wade 1973) that does not treat the unborn as constitutional persons under the Fourteenth Amendment. Therefore, Nelson claims that within the U.S. legal system any vital interests of (...) pregnant women must always take precedence over fetuses’ interests. While agreeing with the main thesis of the article, we believe that the author’s argument neither vindicates his claim, nor explains why those who believe that fetuses are equally protectable human beings do not have the right to refuse to perform an abortion in lifethreatening emergency circumstances (AE). Therefore, the main aim of our commentary is to outline, by referring to our earlier works on conscientious objection in health care (Z_ uradzki 2016) and cultural exemptions (Ciszewski 2016), a better and universalizable argumentative path that would lead to the same conclusion. (shrink)

This is a review of Anita Guerrini's Experimenting with Humans and Animals: From Galen to Animal Rights (Johns Hopkins University Press, 2003).

It is commonly argued that a serious right to life is grounded only in actual, relatively advanced psychological capacities a being has acquired. The moral permissibility of abortion is frequently argued for on these grounds. Increasingly it is being argued that such accounts also entail the permissibility of infanticide, with several proponents of these theories accepting this consequence. We show, however, that these accounts imply the permissibility of even more unpalatable acts than infanticide performed on infants: organ harvesting, live experimentation, (...) sexual interference, and discriminatory killing. The stronger intuitions against the permissibility of these ‘pre-personal acts’ allow us to re-establish a comprehensive and persuasive reductio against psychological accounts of persons. (shrink)

This article addresses the ethics of betel nut use in Taiwan. It first presents scientific facts about the betel quid and its consumption and the generally accepted negative health consequences associated with its use: oral and esophageal cancer, coronary artery disease, metabolic diseases, and adverse effects in pregnancy. It then analyzes the cultural background and economic factors contributing to its popularity in Asia. The governmental and institutional attempts to curb betel nut cultivation, distribution, and sales are also described. Finally, the (...) article analyzes the bioethical implications of this often-ignored subject from the perspectives of human dignity, the good of health, vulnerable groups, cultural diversity, informed consent, and ethical blind spots. (shrink)

What Ivan Illich regarded in his Medical Nemesis as the ‘expropriation of health’ takes place on the surfaces and in the spaces of the screens all around us, including our cell phones but also the patient monitors and (increasingly) the iPads that intervene between nurse and patient. To explore what Illich called the ‘age of the show’, this essay uses film examples, like Creed and the controversial documentary Vaxxed, and the television series Nurse Jackie. Rocky’s cancer in his last film (...) (submitting to chemo to ‘fight’ cancer) highlights what Illich along with Petr Skrabanek called the ‘expropriation of death’. In contrast to what Illich denotes as ‘Umsonstigkeit’ – i.e., a free gift, given undeservedly, i.e., gratuitously – medical science tends to be tempted by what Illich terms scientistic ‘black magic’, taking over (expropriating) the life and the death of the patient in increasingly technological ways, a point underscored in the concluding section on the commercial prospects of xenotransplants using factory farm or mass-produced (and already for some time) human-pig mosaics or chimeras. (shrink)

Personal Health Monitoring (PHM) uses electronic devices which monitor and record health-related data outside a hospital, usually within the home. This paper examines the ethical issues raised by PHM. Eight themes describing the ethical implications of PHM are identified through a review of 68 academic articles concerning PHM. The identified themes include privacy, autonomy, obtrusiveness and visibility, stigma and identity, medicalisation, social isolation, delivery of care, and safety and technological need. The issues around each of these are discussed. The system (...) / lifeworld perspective of Habermas is applied to develop an understanding of the role of PHMs as mediators of communication between the institutional and the domestic environment. Furthermore, links are established between the ethical issues to demonstrate that the ethics of PHM involves a complex network of ethical interactions. The paper extends the discussion of the critical effect PHMs have on the patient’s identity and concludes that a holistic understanding of the ethical issues surrounding PHMs will help both researchers and practitioners in developing effective PHM implementations. (shrink)

Can doctors maintain good character? This paper shifts the focus from patient care to ethical considerations that bear on the physician and impact her as a person. By decentering patient care, the paper highlights certain factors that habituate a particular way of reasoning that is not conducive to inculcating good character. Such factors include, standards of professionalism, being influenced by external monitors, and emphasis on adherence to guidelines. While such factors may benefit patients, they often adversely affect the character of (...) physicians. (shrink)

This article analyses the phenomenon of epistemic injustice within contemporary healthcare. We begin by detailing the persistent complaints patients make about their testimonial frustration and hermeneutical marginalization, and the negative impact this has on their care. We offer an epistemic analysis of this problem using Miranda Fricker's account of epistemic injustice. We detail two types of epistemic injustice, testimonial and hermeneutical, and identify the negative stereotypes and structural features of modern healthcare practices that generate them. We claim that these stereotypes (...) and structural features render ill persons especially vulnerable to these two types of epistemic injustice. We end by proposing five avenues for further work on epistemic injustice in healthcare. (shrink)

ABSTRACTMany recent articles argue that participants who seroconvert during HIV prevention trials deserve treatment when they develop AIDS, and there is a general consensus that the participants in HIV/AIDS treatment trials should have continuing post‐trial access. As a result, the primary concern of many ethicists and activists has shifted from justifying an obligation to treat trial participants, to working out mechanisms through which treatment could be provided. In this paper I argue that this shift frequently conceals an important assumption: that (...) if there is an obligation to supply treatment, then any party who could provide it may be prevailed upon to discharge the obligation. This assumption is false. The reasons why trial participants should get ART affect who has the duty to provide it. We should not burden governments with the obligations of sponsors, nor researchers with the obligations of the international community. And we should not deprive a group of treatment because their need is less salient than that of research participants. Insisting otherwise may lead to people being wrongfully deprived of access to antiretrovirals. (shrink)

Review of British Medical Association handbook on human rights and doctors.

Three common ethical principles for establishing the limits of parental authority in pediatric treatment decision making are the harm principle, the principle of best interest, and the threshold view. This paper consider how these principles apply to a case of a premature neonate with multiple significant comorbidities whose mother wanted all possible treatments, and whose health care providers wondered whether it would be ethically permissible to allow him to die comfortably despite her wishes. Whether and how these principles help to (...) understand what was morally right for the child is questioned. The paper concludes that the principles were of some value in understanding the moral geography of the case, but that the case reveals common bioethical principles for medical decision making are problematically value-laden because they are inconsistent with the widespread moral value of medical vitalism. (shrink)

The volume of clinical research is increasing exponentially—far beyond our ability to process and absorb the results. Given this situation, it may be beneficial to consider reducing the flow at its source. In what follows, I will motivate and critically evaluate the following proposal: researchers should conduct fewer clinical trials. More specifically, I c onsider whether researchers should be permitted to conduct only clinical research of very high quality and, in turn, whether research ethics committees should prohibit all other, lower-quality (...) research, even when it might appear to meet some minimal ethical standard. Following a close analysis of the social-value requirement of ethical clinical research, I argue that this proposal is defensible. The problem identified in this paper has two parts, quantity and quality, and some clarification is needed about the latter because “quality” is a highly contested term in the medical literature. When some scholars advocate for high-quality trials, they mean large-scale, simple, explanatory randomized controlled trials. Others, including myself, have defended a different characterization of high-quality research that tends more toward pragmatic trial design and the use of methods other than RCTs. Pragmatic trials aim to provide evidence that directly supports clinical decision-making in “usual” care settings. Unlike explanatory trials, which aim to abstract away from particular settings and patients, in the hopes of creating ideal conditions for the success of an intervention, pragmatic trials deliberately pursue knowledge of high applicability, through the use of representative subjects, clinically important questions, flexible treatment protocols, patient-oriented outcome measures, and so on. I see applicability as a marker of high-quality research. The context in which research is meant to be applied should be the context in which new interventions are evaluated. (shrink)

Bioethical discourse on organ donation covers a wide range of topics, from informed consent procedures and scarcity issues up to ‘transplant tourism’ and ‘organ trade’. This paper presents a ‘depth ethics’ approach, notably focussing on the tensions, conflicts and ambiguities concerning the status of the human body. These will be addressed from a psychoanalytical angle. First, I will outline Lacan’s view on embodiment as such. Subsequently, I will argue that, for organ recipients, the donor organ becomes what Lacan refers to (...) as an object a, the ‘partial object’ of desire, the elusive thing we are deprived of, apparently beyond our grasp. Within the recipient’s body an empty space emerges, a kind of ‘vacuole’, once occupied by a faltering organ. This space can only be filled by a ‘gift’ from the other, by an object a. Once implanted, however, this implant becomes an ‘extimate’ object: something both ‘external’ and ‘intimate’, both ‘embedded’ and ‘foreign’, and which is bound to remain an object of concern for quite some time, if not for life. A Lacanian analysis allows us, first of all, to address the question what organ transplantation has in common with other bodily practices involving bodily parts procured from others, such as cannibalism. But it also reveals the basic difference between the two, as well as the distance between the ‘fragmented body’ of Frankenstein’s ‘monster’—as an aggregate of replaceable parts—and the multiple organ recipients of today. (shrink)

The general aim of this article is to give a critical interpretation of post-trial obligations towards individual research participants in the Declaration of Helsinki 2013. Transitioning research participants to the appropriate health care when a research study ends is a global problem. The publication of a new version of the Declaration of Helsinki is a great opportunity to discuss it. In my view, the Declaration of Helsinki 2013 identifies at least two clearly different types of post-trial obligations, specifically, access to (...) care after research and access to information after research. The agents entitled to receive post-trial access are the individual participants in research studies. The Declaration identifies the sponsors, researchers and host country governments as the main agents responsible for complying with the post-trial obligations mentioned above. To justify this interpretation of post-trial obligations, I first introduce a classification of post-trial obligations and illustrate its application with examples from post-trial ethics literature. I then make a brief reconstruction of the formulations of post-trial obligations of the Declaration of Helsinki from 2000 to 2008 to correlate the changes with some of the most salient ethical arguments. Finally I advance a critical interpretation of the latest formulation of post-trial obligations. I defend the view that paragraph 34 of ‘Post-trial provisions’ is an improved formulation by comparison with earlier versions, especially for identifying responsible agents and abandoning ambiguous ‘fair benefit’ language. However, I criticize the disappearance of ‘access to other appropriate care’ present in the Declaration since 2004 and the narrow scope given to obligations of access to information after research. (shrink)

In this article I clarify the concepts of ‘pain’, ‘suffering’. ‘pains of body’, ‘pains of soul’. I explore the relevance of an ethic to the clinical setting which gives patients a strong prima facie right to freedom from unnecessary and unwanted pain and which places upon medical professionals two concomitant moral obligations to patients. First, there is the duty not to inflict pain and suffering beyond what is necessary for effective diagnosis. treatment and research. Next, there is the duty to (...) do all that can be done to relieve all the pain and suffering which can be alleviated. I develop in some detail that individuality of pain sensitivity must be taken into account in fulfihing these obligations. I explore the issue of the relevance of informed consent and the right to refuse treatment to the matter of pain relief. And I raise the question of what conditions, if anv, should override the right to refuse treatment where pain relief is of paramount concern. (shrink)

There has been a growing concern over establishing norms that ensure the ethically acceptable and scientifically sound conduct of clinical trials. Among the leading norms internationally are the World Medical Association's Declaration of Helsinki, guidelines by the Council for International Organizations of Medical Sciences, the International Conference on Harmonization's standards for industry, and the CONSORT group's reporting norms, in addition to the influential U.S. Federal Common Rule, Food and Drug Administration's body of regulations, and information sheets by the Department of (...) Health and Human Services. There are also many norms published at more local levels by official agencies and professional groups.Any account of international standards should cover both scientific and ethical norms at once – the two are conceptually intertwined. Recent sources recognize that “[s]cientifically unsound research on human subjects is unethical in that it exposes research subjects to risks without possible benefit.”. (shrink)

Although ethics is an essential component of undergraduate medical education, research suggests current medical ethics curricula face considerable challenges in improving students’ ethical reasoning. This paper discusses these challenges and introduces a promising new mode of graduate and professional ethics instruction for overcoming them. We begin by describing common ethics curricula, focusing in particular on established problems with current approaches. Next, we describe a novel method of ethics education and assessment for medical students that we have devised, the Medical Ethics (...) Bowl. Finally, we suggest pedagogical advantages to MEBs when compared to other ethics curricula. (shrink)

In accordance with a recent statement released by the World Health Organization, the Canadian province of Ontario is moving to ban payment for plasma donation. This is partially based on contentions that remuneration for blood and blood products undermines autonomy and personal dignity. This paper is dedicated to evaluating this claim. I suggest that traditional autonomy-based arguments against commodification of human body parts and substances are less compelling in the context of plasma donation in Canada, but that there is another (...) autonomy-based objection to paid plasma donation that has not received sufficient attention. Namely, the stigma that surrounds exchanging plasma for payment makes it difficult to make an autonomous decision to engage in this activity. I suggest that this problem can be overcome in one of two ways; by banning payment for plasma, or by reducing the stigma surrounding this practice. I provide an indication of how we might work to achieve the latter, contending that this possibility should be taken seriously, due to the difficulties in achieving a sufficient supply of plasma without remuneration. (shrink)

The concepts of placebos and placebo effects refer to extremely diverse phenomena. I recommend dissolving the concepts of placebos and placebo effects into loosely related groups of specific mechanisms, including expectation-fulfillment, classical conditioning, and attentional-somatic feedback loops. If this approach is on the right track, it has three main implications for the ethics of informed consent. First, because of the expectation-fulfillment mechanism, the process of informing cannot be considered independently from the potential effects of treatment. Obtaining informed consent influences the (...) effects of treatment. This provides support for the authorized concealment and authorized deception paradigms, and perhaps even for outright deceptive placebo use. Second, doctors may easily fail to consider the potential benefits of conditioning, leading them to misjudge the trade-off between beneficence and autonomy. Third, how attentional-somatic feedback loops play out depends not only on the content of the informing process but also on its framing. This suggests a role for libertarian paternalism in clinical practice. (shrink)

Reflecting on group theory within clinical supervision offers useful vantage points from which to engage nursing and the helping professions in the task of supervisory practice. This paper presents reflective experiences of group clinical supervision training and practice through a critique of Hawkins and Shohet’s process centred model. The underlying premise of transference hypothesis is that experiences and memories from the past inform present behaviours. Little has been written about the hypothesis in relation to clinical supervision in nursing and the (...) helping professions. However, the hypothesis was criticised by John M. Shlien in the 1980s and remains pertinent today due to expansion into social and healthcare practice. Reflective autobiographical diary entries focus on the model’s two latter stages which propose the use of Sigmund Freud’s transference hypothesis. The work of Freud, Foulkes, Heidegger and Hawkins and Shohet are synthesised and conclude with a phenomenological suggestion that immediacy and openness are necessary ontological conditions for group clinical supervision. Valuing empathic attunement to better understand group clinical supervision may be more important than theoretical distractions for non-therapeutic clinical supervision practice. (shrink)

Appropriate information and consent has been one of the most intensely discussed topics within the context of biobank research. In parallel to the normative debate, many socio-empirical studies have been conducted to gather experiences, preferences and views of patients, healthy research participants and further stakeholders. However, there is scarcity of literature which connects the normative debate about justifications for different consent models with findings gained in empirical research. In this paper we discuss findings of a limited review of socio-empirical research (...) on patients’ and healthy research participants’ experiences and views regarding consent to biobank research in light of ethical principles for appropriate information and consent. (shrink)

What are the ontological commitments in Hegel and Heidegger’s discussion of the self? In this essay I approach these continental thinkers with a question from analytic philosophy, to see how they might respond. In different ways Hegel and Heidegger try to locate the question within a prior discourse about the conditions of the possibility of any local ontological commitments. The priority they claim can be clarified by distinguishing conditions of possibility from conditions of actuality.