Suzie loves to talk. A successful mid-thirties businesswoman, she is a self-described social butterfly—which made her diagnosis of tongue cancer even more devastating. She came to the clinic complaining of a lump in her throat, which in most young healthy people turns out to be benign and easily treated. But not for Suzie, who had a very rare salivary tumor arising in the back of her tongue. Its slow growth was both a blessing and a curse; such tumors do not (...) kill people quickly, but they typically require surgery. It would slowly and relentlessly grow until and unless we removed most of her tongue. In head and neck surgery, issues of appearance, identity, function, and communication are the foremost considerations when we decide when, and whether, to operate. As the adage goes, knowing when not to operate is the sine qua non of the wise surgeon. But the inverse is also true. (shrink)

On occasions, laws on consent are subject to modification, largely on account of being subject to common law rather than statute—for example, in the UK. Guideline publications such as the UK Department of Health Reference Guide to Consent for Examination or Treatment are intended to provide information for clinicians on when and how to apply current laws in everyday clinical situations. While the extent to which guidelines influence clinician behaviour depends on how much they are read and followed, what is (...) also relevant, and sometimes omitted from consideration, is discussion about underlying philosophical concepts.This paper analyses philosophical weaknesses relating to English laws on consent, the main focus of attention being applied ethics and the rights of adults with incapacity. It draws comparisons between the US and the UK, and advocates changes in English law in order to help rectify weaknesses in patient protection. Discussion includes references to Scottish law, and the use of advance directives, and it voices concerns about over-reliance on “best interests” determinations. The problem is partly one of logical analysis, and what can happen is that best interests determinations fail to show proper respect for adults lacking the capacity to consent to examination or treatment on their own behalf. This is fundamentally a matter of rights, and requires further investigation and appropriate legal remedies in order to respond to ethical deficiencies in English law as it now stands. (shrink)

In interprofessional clinical teams, the patients have interpersonal relationships with several practitioners. The aim of this study was to explore patients’ and practitioners’ perceptions of how such relationships may contribute to promote the whole team’s respect for the patient’s autonomy, as interpersonal patient–provider relationships may contribute to enhance patient autonomy. Sixteen qualitative in-depth interviews were conducted with 12 informants, including patients, nurses, physiotherapists, and physicians from three rehabilitation teams. Data were analysed according to Grounded Theory procedures. The informants discussed interpersonal (...) relationships as an integral and significant part of the team work. The practitioners tried to adjust their professional approach to the patients’ genuine opinions and let patients decide the teams’ goals. Close relationships with patients could be important to accomplish this, particularly described by nurses and physiotherapists, who could facilitate the communication with the rest of the team. (shrink)

In situations where experience shows that a particular intervention will not benefit a patient, common sense seems to suggest that the intervention should not be used. Yet it is precisely in these situations that a peculiar ethic begins to operate, an ethic that Eddy calls “the criterion of potential benefit.” According to this ethic, “a treatment is appropriate if it might have some benefit.” Thus, the various maxims learned in medical school instruct physicians that “‘an error of commission is to (...) be preferred to an error of omission,’ or ‘when in doubt, cut it out’ or ‘if but one patient is helped, then the treatment is worthwhile.’”. (shrink)

We argue that a turn toward virtue ethics as a way of understanding medical professionalism represents both a valuable corrective and a missed opportunity. We look at three ways in which a closer appeal to virtue ethics could help address current problems or issues in professionalism education—first, balancing professionalism training with demands for professional virtues as a prerequisite; second, preventing demands for the demonstrable achievement of competencies from working against ideal professionalism education as lifelong learning; and third, avoiding temptations to (...) dismiss moral distress as a mere “hidden curriculum” problem. As a further demonstration of how best to approach a lifelong practice of medical virtue, we will examine altruism as a mean between the extremes of self-sacrifice and selfishness. (shrink)

In this paper, I have tried to develop a critique of committee procedures and conflict of interest within research advisory committees and ethical review committees (ERCs). There are specific features of conflict of interest in medical research. Scientists, communities and the subjects of research all have legitimate stakeholdings. The interests of medical scientists are particularly complex, since they are justified by the moral and physical welfare of their research subjects, while the reputations and incomes of scientists depend on the success (...) of their science. Tensions of this kind must at times produce conflict of interest. It is important to recognise that conflicts of interest may unwittingly lead to manipulation of research subjects and their lay representatives on research committees. It is equally important to recognise distinctions between the legal and moral aspects of conflict of interest. Some practical suggestions are made which may go some way towards resolving these difficulties. They indicate what might be needed to ensure the validity of ethical discourse, and to reduce the risks associated with conflict of interest. (shrink)

Patients’ trust in their physicians improves their health outcomes because of better compliance, more disclosure, stronger placebo effect, and more physicians’ trustworthy behaviors. Patients’ autonomy may also impact on health outcomes and is increasingly being emphasized in health care. However, despite the critical role of trust and autonomy, patients that naïvely trust their physicians may become overly dependent and lack the motivation to participate in medical care. In this article, we argue that increased trust does not necessarily imply decreased autonomy. (...) Furthermore, patients with high levels of trust and autonomy preferences are most likely to have the best health outcomes. We propose a framework for understanding simultaneous trust and autonomy preferences and for recognizing their interactive effects on health outcomes in the dynamic medical encounter. This framework argues that policy makers and health care providers should make efforts to foster not only patients’ trust but also their preferences for autonomy and thus gain the best position for achieving health-related goals. (shrink)

In this paper we address the question of how it can be possible for a non-expert to acquire justified true belief from expert testimony. We discuss reductionism and epistemic trust as theoretical approaches to answer this question and present a novel solution that avoids major problems of both theoretical options: Performative Expert Testimony (PET). PET draws on a functional account of expertise insofar as it takes the expert’s visibility as a good informant capable to satisfy informational needs as equally important (...) as her specific skills and knowledge. We explain how PET generates justification for testimonial belief, which is at once assessable for non-experts and maintains the division of epistemic labor between them and the experts. Thereafter we defend PET against two objections. First, we point out that the non-expert’s interest in acquiring widely assertable true beliefs and the expert’s interest in maintaining her status as a good informant counterbalances the relativist account of justification at work in PET. Second, we show that with regard to the interests at work in testimonial exchanges between experts and non-experts, PET yields a better explanation of knowledge-acquisition from expert testimony than externalist accounts of justification such as reliabilism. As our arguments ground in a conception of knowledge, which conceives of belief-justification as a declarative speech act, throughout the rearmost sections of this paper we also indicate to how such a conception is operationalized in PET. (shrink)

Advance directives for psychiatric care are the subject of debate in a number of Western societies. By using psychiatric advance directives , it would be possible for mentally ill persons who are competent and with their disease in remission, and who want timely intervention in case of future mental crisis, to give prior authorisation to treatment at a later time when they are incompetent, have become non-compliant, and are refusing care. Thus the devastating consequences of recurrent psychosis could be minimised.Ulysses (...) contracts raise a number of ethical questions. In this article the central issues of concern and debate are discussed from a narrative perspective. Ulysses contracts are viewed as elements of an ongoing narrative in which patient and doctor try to make sense of and get a hold on the recurrent crises inherent in the patient's psychiatric condition. (shrink)

Extending literature on health information to entertainment television, we analyze the prostate cancer narrative presented in the police drama, NYPD Blue. We explain how the physician-patient interaction depicted on the show followed (and sometimes did not follow) the medical dialogue model. Findings reveal that the producers of this show advocate a more dialogic model of medical interaction. Portrayals of incompetent, ineffective physicians are contrasted with the superior, effective efforts of other physicians. The audience learns that a non-dialogic approach characterizes “bad (...) doctors,” while the dialogic method typifies “good doctors.” Likewise, medical professionals can use such texts to enhance physician-patient interaction. (shrink)

Power is an inescapable aspect of all socialrelationships, and inherently is neither goodnor evil. Doctors need power to fulfil theirprofessional obligations to multipleconstituencies including patients, thecommunity and themselves. Patients need powerto formulate their values, articulate andachieve health needs, and fulfil theirresponsibilities. However, both parties canuse or misuse power. The ethical effectivenessof a health system is maximised by empoweringdoctors and patients to develop `adult-adult'rather than `adult-child' relationships thatrespect and enable autonomy, accountability,fidelity and humanity. Even in adult-adultrelationships, conflicts and complexitiesarise. Lack of (...) concordance between doctors andpatients can encourage paternalism but may bebest resolved through negotiated care. Afurther area of conflict involves the `doubleagency' of doctors for both patients and thecommunity. Empowerment of all players is notalways possible but is most likely where eachparty considers and acknowledges power issues. (shrink)

Twenty-five years after the term "therapeutic misconception’ (TM) first entered the literature, most commentators agree that it remains widespread. However, the majority of scholarly attention has focused on the reasons why a patient cum human subject might confuse the goals of research with the goals of therapy. Although this paper addresses the social and cultural factors that seem to animate the TM among subjects, it also fills a niche in the literature by examining why investigators too might operate under a (...) similar confusion. In framing these issues, the paper expressly adopts a Wittgensteinian approach to evaluating the TM, suggesting that interlocutors do not need any analytic definition of the TM to use the term meaningfully in thinking about the moral implications of the TM in practice. (shrink)

Medical educators invoke professionalism as a core competency in curricula. This paper criticizes classic definitions. It also identifies some negative traits of medicine as a profession. The call to professionalism is naive nostalgia. Straightforward didactics in professionalism cannot do the desired work in medical education. The most we can say is that students should adopt the good aspects of professionalism and the profession should stop being some of what it has been. This is a platitude. If the notion is to (...) be more than shallow, each student and practitioner will have to engage in much dialogue, reflection and refinement over many years. (shrink)

Objectives—To assess whether UK and US health care professionals share the views of medical ethicists about medical futility, withdrawing/withholding treatment, ordinary/extraordinary interventions, and the doctrine of double effectDesign, subjects and setting–A 138-item attitudinal questionnaire completed by 469 UK nurses studying the Open University course on “Death and Dying” was compared with a similar questionnaire administered to 759 US nurses and 687 US doctors taking the Hastings Center course on “Decisions near the End of Life”.Results–Practitioners accept the relevance of concepts widely (...) disparaged by bioethicists: double effect, medical futility, and the distinctions between heroic/ordinary interventions and withholding/ withdrawing treatment. Within the UK nurses' group a “rationalist” axis of respondents who describe themselves as having “no religion” are closer to the bioethics consensus on withholding and withdrawing treatment.Conclusions—Professionals' beliefs differ substantially from the recommendations of their professional bodies and from majority opinion in bioethics. Bioethicists should be cautious about assuming that their opinions will be readily accepted by practitioners. (shrink)

‘Doing good medical ethics’ involves attending to both the biomedical and existential aspects of illness. For this, we need to bring in a phenomenological perspective to the clinical encounter, adopt a virtue-based ethic and resolve to re-evaluate the goals of medicine, in particular the alleviation of suffering and the role of compassion in everyday ethics.

Let us look at autonomy in a new way. Autonomy has a richly deserved place of honor in bioethlcs. It has led the set of principles that formed the basis of the discipline since the beginning. It is the leading principle In what is now regularly called “the Georgetown Mantra,” a phrase suggested by one of the first philosophers ever to be hired In a medical school, K. Danner Clouser. The phrase applies to the principled approach of autonomy, beneficence, nonmaleficence, (...) and justice. This kind of bioethics was developed by scholars like Beauchamp and Childress, Veatch, and Engelhardt, during their association with Georgetown University. (shrink)

To address certain seemingly irresolvable conflicts between patients and clinicians regarding treatment plans that are rooted in patients' religious or spiritual beliefs, Kuczewski (2007), in a ref...

A request that an ethics committee or consultant analyze the ethical issues in a case, delineate ethical options, or make a recommendation need not automatically but often does elicit legal information. In a recent book in which ethics consultants described cases on which they had worked, almost all cited a legal case or statute that had shaped the consultation process. During a period of just a few months, case consultation done under the auspices of one university hospital ethics committee involved (...) interpretation of statutes on living wills, durable powers of attorney, competency, confidentiality, guardianship, AIDS testing, and disability. At another hospital, 30% of ethics consultations were thought to involve legal issues. Attorneys at a third hospital estimated that virtually every case involves legal issues. The notion that ethics consultation is an “amalgam” of medicine, ethics, interpersonal skills, and law is gaining currency. Ethics consultation has become a channel through which law enters the clinical setting. (shrink)

Wojtasiewicz (2006) raises an intriguing and concerning possibility: that end-of-life conflict resolution processes—“futility” policies—may compound discrimination against African Americans, who ha...

A standard view in ethics is that ethical issues concern a different range of human concerns than does politics. This essay goes beyond the long-standing dispute about the extent to which applied ethics needs a commitment to ethical theory. It argues that regardless of the outcome of that dispute, applied ethics, because it presumes something about the nature of authority, rests upon and is implicated in political theory. After internalist and externalist accounts of applied ethics are described, “mixed” approaches are (...) considered that contain inevitable political dimensions. A feminist alternative, Walker’s metaethic of responsibility, shows that authority is best understood as relational and that situations of unequal power are therefore often the places where applied ethics arises. Furthermore, in a democratic society, commitments to democracy should shape the account of authority, and, thus, the nature of applied ethics as well. (shrink)

Past ages of medical care are condemned in modern philosophical and medical literature as being too paternalistic. The normal account of good medicine in the past was, indeed, paternalistic in an offensive way to modern persons. Imagine a Jean Paul Sartre going to the doctor and being treated without his consent or even his knowledge of what will transpire during treatment! From Hippocratic times until shortly after World War II, medicine operated in a closed, clubby manner. The knowledge learned in (...) medicine was not shared with the patients, who were in general poorly educated and for the most part completely ignorant of the craft of medicine and the physicians (but not, perhaps, of folk medicine). Physicians were cautioned against telling patients too much about their Illness and/or their recovery, perhaps because physicians themselves did not have an enormous armamentarium to confront disease. (shrink)

Psychiatry is increasingly dominated by the reductionist claim that mental illness is caused by neurobiological abnormalities such as chemical imbalances in the brain. Critical psychiatry does not believe that this is the whole story and proposes a more ethical foundation for practice. This book describes an original framework for renewing mental health services in alliance with people with mental health problems. It is an advance over the polarization created by the "anti-psychiatry" of the past.

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)