In this paper, we argue that promoting patient values is a legitimate goal of medicine. Our view offers a justification for certain current practices, including birth control and living organ donation, that are widely accepted but do not fit neatly within the most common extant accounts of the goals of medicine. Moreover, we argue that recognising value promotion as a goal of medicine will expand the scope of medical practice by including some procedures that are sometimes rejected as being outside (...) the scope of acceptable medical practice, such as certain forms of physician-assisted death. We then rebut some common and possible objections to this view. Our aim is not to argue that other accounts are mistaken—except when they argue for a single goal that does not include patient values—but rather to show that value promotion should play a more central role in discussions about the goals of medicine. (shrink)

The literature on conscientious objection in medicine presents two key problems that remain unresolved: Which conscientious objections in medicine are justified, if it is not feasible for individual medical practitioners to conclusively demonstrate the genuineness or reasonableness of their objections? How does one respect both medical practitioners’ claims of conscience and patients’ interests, without leaving practitioners complicit in perceived or actual wrongdoing? My aim in this paper is to offer a new framework for conscientious objections in medicine, which, by bringing (...) medical professionals’ conscientious objection into the public realm, solves the justification and complicity problems. In particular, I will argue that: an “Uber Conscientious Objection in Medicine Committee” —which includes representatives from the medical community and from other professions, as well as from various religions and from the patient population—should assess various well-known conscientious objections in medicine in terms of public reason and decide which conscientious objections should be permitted, without hearing out individual conscientious objectors; medical practitioners should advertise their conscientious objections, ahead of time, in an online database that would be easily accessible to the public, without being required, in most cases, to refer patients to non-objecting practitioners. (shrink)

Bioethics has increasingly become a standard part of medical school education and the training of healthcare professionals more generally. This is a promising development, as it has the potential to help future practitioners become more attentive to moral concerns and, perhaps, better moral reasoners. At the same time, there is growing recognition within bioethics that nonideal theory can play an important role in formulating normative recommendations. In this chapter we discuss what this shift toward nonideal theory means for ethical curricula (...) within healthcare education. In particular, we contend that more attention to the particularities of historical and social context needs to be incorporated into bioethics training. To make this argument, we focus on two examples: teaching units on race and medicine and those that focus on stigma and coercion in mental health. For both, we show how a pedagogical approach in which educators focus on social injustice could influence how practitioners engage in ethics in the clinic. This chapter, then, demonstrates what a commitment to nonideal theory can mean practically when it comes to bioethics education. (shrink)

After describing the disorder of psychopathy, I examine the theories and the evidence concerning the psychopaths’ deficient moral capacities. I first examine whether or not psychopaths can pass tests of moral knowledge. Most of the evidence suggests that they can. If there is a lack of moral understanding, then it has to be due to an incapacity that affects not their declarative knowledge of moral norms, but their deeper understanding of them. I then examine two suggestions: it is their deficient (...) practical reason or their stunted emotions that are at fault. The evidence supports both explanations. I conclude with an overview of the debate concerning whether they are morally or legally responsible for their actions. (shrink)

Similarly to other accounts of disease, Christopher Boorse’s Biostatistical Theory (BST) is generally presented and considered as conceptual analysis, that is, as making claims about the meaning of currently used concepts. But conceptual analysis has been convincingly critiqued as relying on problematic assumptions about the existence, meaning, and use of concepts. Because of these problems, accounts of disease and health should be evaluated not as claims about current meaning, I argue, but instead as proposals about how to define and use (...) these terms in the future, a methodology suggested by Quine and Carnap. I begin this article by describing problems with conceptual analysis and advantages of “philosophical explication,” my favored approach. I then describe two attacks on the BST that also question the entire project of defining “disease.” Finally, I defend the BST as a philosophical explication by showing how it could define useful terms for medical science and ethics. (shrink)

According to some proponents of an empirical medical ethics, medical ethics should take the experience, insights, and arguments of doctors and other medical practitioners as their point of departure. Medical practitioners are supposed to have ‘moral wisdom.’ In this view, the moral beliefs of medical practitioners have a special status. In sections I-IV, I discuss two possible defences of such a status. The first defence is based on the special status of the moral beliefs of the health professional as an (...) expert in medical ethics, and the second defence on the special status of the health professional’s moral beliefs as a practitioner. The first defence is built up around the opposition between experts and laypersons, while the second defence rests on the opposition between practitioners and theorists. In sections V and VI, I examine the interrelations between empirical ethics and anti-theory in ethics. Some regard empirical ethics as a laudable alternative to theory-driven normative ethics. I explore their objections against ethical theory and ethical theorising, and conclude that they are not valid. In the last section, VII, I discuss the role of ethicists in medical practice. (shrink)

It is plausible that what possible courses of action patients may legitimately expect their physicians to take is ultimately determined by what medicine as a profession is supposed to do and, consequently, that we can determine the moral acceptability of voluntary euthanasia and physician-assisted suicide on the basis of identifying the proper goals of medicine. This article examines the main ways of defining the proper goals of medicine found in the recent bioethics literature and argues that they cannot provide a (...) clear answer to the question of whether or not voluntary euthanasia and physician-assisted suicide are morally acceptable. It is suggested that to find a plausible answer to this question and to complete the task of defining the proper goals of medicine, we must determine what is the best philosophical theory about the nature of prudential value. (shrink)

It has been claimed that there are certain acts that nurses as people practising nursing must never do because they are nurses and this is regardless of what the same agent should do; that certain actions are not part of proper nursing practice. The concept of an internal morality has been discussed in relation to medicine and has been used to ground the actions proper to medicine in a realist tradition. Although the concept of an internal morality of nursing is (...) not explicitly mentioned in the literature the underpinning ideas about the proper practice of nursing based on philosophical realism I argue equate with it and a discussion of the method of an internal morality can help to understand how arguments against euthanasia related to the profession of nursing are far from clear. Ultimately, although the idea of particular acts proper to nurses qua nurses is not clear, the concept of an internal morality can help to get practitioners to see how the profession is tightly linked to moral actions, even so the hard problems in bioethics such as the morality of euthanasia remain hard for all and the easy ones easy for all. (shrink)

The Hippocratic Oath and the Declaration of Geneva of the World Medical Association are compared in terms of content and origin. Their relevance for current medical practice is investigated. The status which is ascribed to these documents will be shown and the status which they can reasonably claim to have will be explored. Arguments in favor of the Hippocratic Oath that rely on historical stability or historical origin are being examined. It is demonstrated that they get caught up in paradoxes. (...) Should doctors swear the Hippocratic Oath or the Declaration of Geneva? The Hippocratic Oath is a remarkable historic document, which contains important elements still relevant for medical ethics today. Its interpretation as a timeless, still valid medical code is unfounded. The historical arguments, that should justify its validity, are untenable. The Declaration of Geneva, and not the Hippocratic Oath, can legitimately claim to come close to representing the most important principles of professional medical conduct in today’s globalised world. (shrink)

Sometimes physicians lie to third-party payers in order to grant their patients treatment they would otherwise not receive. This strategy, commonly known as gaming the system, is generally condemned for three reasons. First, it may hurt the patient for the sake of whom gaming was intended. Second, it may hurt other patients. Third, it offends contractual and distributive justice. Hence, gaming is considered to be immoral behavior. This article is an attempt to show that, on the contrary, gaming may sometimes (...) be a physician's duty. Under specific circumstances, gaming may be necessary from the viewpoint of the internal morality of medicine. Moreover, the objections against gaming are examples of what we call the idealistic fallacy, that is, the fallacy of passing judgments in a nonideal world according to ideal standards. Hence, the objections are inconclusive. Gaming is sometimes justified, and may even be required in the name of beneficence. (shrink)

W artykule w trojaki sposób dowodzę odrębności profesjonalnej etyki lekarskiej, mianowicie: 1. ukazując różnice pozycji normatywnej obowiązków w etyce profesjonalnej i ogólnej, 2. uzasadniając przynależność lekarskiej etyki profesjonalnej do modelu zapożyczenia jako typu etyki aplikacyjnej, 3. podając racje za profesjonalizmem historycznym jako etyką właściwą dla stanu lekarskiego. Odrębność profesjonalnej etyki lekarskiej stanowi ważny argument za jej umieszczeniem w planie edukacji etycznej studentów medycyny i lekarzy. W końcowej części pracy rekonstruuję rzeczywiste i postulowane relacje między etyką profesjonalną a profesjonalizmem, bioetyką akademicką (...) i bioetyką publiczną. Celem rekonstrukcji jest wskazanie optymalnego dla edukacji etycznej miejsca etyki profesjonalnej w systemie kształcenia etycznego profesjonalistów. (shrink)

Clear and careful thinking is an indispensable aid in the pursuit of answers to the difficult ethical question faced by clinicians, patients, and families. In this issue of The Journal of Medicine and Philosophy devoted to issues in clinical ethics, the authors engage in this enterprise by reflecting on morally good medical decision making, conscientious objection, presumed consent in organ donation, the permissibility of surrogate decision making, and the failure of legislative limits on the scope of euthanasia in Belgium.

Conceptual clarity is essential when engaging in dialogue to avoid unnecessary disagreement and to promote mutual understanding. In this issue devoted to clinical bioethics, the authors exemplify the virtue of careful conceptual analysis as they explore complex clinical questions regarding the essential nature of medicine, the boundaries of killing and letting die, the meaning of irreversibility in definitions of death, the argument for a right to try experimental medications, the ethical borders in complex medical billing, and the definition and modeling (...) of complex disease states. (shrink)

The ends of medicine are sometimes construed simply as promotion of health, treatment and prevention of disease, and alleviation of pain. Practitioners might agree that this simple formulation captures much of what medical practice is about. But while the ends of medicine may seem simple or even obvious, the essays in this issue demonstrate the wide variety of philosophical questions and issues associated with the ends of medicine. They raise questions about how to characterize terms like “health” and “disease”; whether (...) medicine’s goals should be extended to include enhancement beyond normal human function; and whether the ends of medicine are binding on those involved in health care outside of professional medicine, such as pharmaceutical companies. They also give philosophical attention to patient experiences, and so raise questions about whether current practices achieve the ends of medicine from the perspective of the patient. Together these essays demonstrate the important role played by a conception of medicine’s ends in a wide variety of issues and problems in the philosophy and ethics of medicine. (shrink)

Edmund Pellegrino and David Thomasma’s writings have had a worldwide impact on discourse about the philosophy of medicine, professionalism, bioethics, healthcare ethics, and patients’ rights. Given their works’ importance, it is surprising that commentators have ignored their admission of an unresolved and troubling dilemma and inconsistency in their theory. The purpose of this article is to identify and state what problems worried them and to consider possible solutions. It is argued that their dilemma stems from their concerns about how to (...) justify professional rules restricting colleagues from performing acts they view as direct, active, and formal killings, such as physician-assisted suicide, mercy killing, and abortion. It is further argued that their inconsistency is that they both assert and deny that professional colleagues should not use their moral or theological values to impose professional restrictions on other colleagues without adequate philosophical grounds. At risk are their arguments about the nature of an internal morality for medicine, a secular and multicultural basis for medical ethics, and a nonarbitrary way to determine what acts fall outside the ends of medicine. These are arguments they claim also apply to other healthcare professions. The article begins with a brief overview of their key positions to provide the context in which they make their admission. (shrink)

Over the past several years, the most widely publicized issue in capital litigation has been the constitutional status of states’ lethal injection protocols. Death row inmates have not challenged the constitutionality of lethal injection itself, but rather execution protocols and their potential for maladministration. The inmates’ concern is due to the three-drug protocol used in the vast majority of capital jurisdictions: if the anesthetic, which is administered first, is ineffectively delivered, then the second and third drugs — the paralytic and (...) heartbeat-ceasing agents — will cause torturous pain and suffering in violation of the Eight Amendment. Inmates have argued that the participation of anesthesiologists or other highly trained medical professionals is constitutionally required to minimize the risk of unnecessary suffering. This litigation, in conjunction with evidence that some executed inmates suffered torturous pain, has reinvigorated the ethical debate about physician participation in executions. Even though the United States Supreme Court has signaled that physician participation is not constitutionally required, lawmakers in death penalty states must consider the ethics of physician involvement. (shrink)

Do pharmaceutical companies have a moral obligation to expand access to investigational drugs to patients outside the clinical trial? One reason for thinking they do not is that expanded access programs might negatively affect the clinical trial process. This potential impact creates dilemmas for practitioners who nevertheless acknowledge some moral reason for expanding access. Bioethicists have explained these reasons in terms of beneficence, compassion, or a principle of rescue, but their arguments have been limited to questions of moral permissibility, leaving (...) for future research the question of whether expanded access is morally obligatory. We take up this further question and argue that pharmaceutical companies have a moral obligation to expand access. Our defense is not based on beneficence, compassion, or rescue, but instead on a reciprocal moral expectation resulting from existing social commitments that help ensure a robust pharmaceutical practice within the broader healthcare system. Our aim is to give this obligation, along with several others, a coherent and plausible structure within the wider clinical trial process so that one might better explain the sources of the dilemmas and their possible resolutions. (shrink)