Libertarian paternalism's notion of “nudging” refers to steering individual decision making so as to make choosers better off without breaching their free choice. If successful, this may offer an ideal synthesis between the duty to respect patient autonomy and that of beneficence, which at times favors paternalistic influence. A growing body of literature attempts to assess the merits of nudging in health care. However, this literature deals almost exclusively with health policy, while the question of the potential benefit of nudging (...) for the practice of informed consent has escaped systematic analysis. This article focuses on this question. While it concedes that nudging could amount to improper exploitation of cognitive weaknesses, it defends the practice of nudging in a wide range of other conditions. The conclusion is that, when ethically legitimate, nudging offers an important new paradigm for informed consent, with a special potential to overcome the classical dilemma between paternalistic beneficence and respect for autonomy. (shrink)

In the spirit of full disclosure, I have been a member of the Delphi panels discussed in this article (Beskow and Weinfurt 2019) since their inception and was one of the people who was recently int...

Genetics offers real opportunities for public health actors. Increased understanding of genetics will illuminate some of the factors that affect disease and, in many cases, will lead to more effective treatments. The recognition that phenylketonuria was caused by a metabolic defect that led to the accumulation of toxic levels of phenylalanine, an elevation that could largely be averted by adopting a low-phenylalanine diet, is an early example. Some cases of what was thought to be Sudden Infant Death Syndrome, a diagnosis (...) used when no etiology is known, now appear to have been caused by metabolic defects in fatty acid oxidation and sodium channel defects. One of the tasks that has already been undertaken by the public health sector is to ensure that genomic information is incorporated into clinical care when the robusmess of findings and their clinical utility have been well defined. (shrink)

Genetics offers real opportunities for public health actors. Increased understanding of genetics will illuminate some of the factors that affect disease and, in many cases, will lead to more effective treatments. The recognition that phenylketonuria was caused by a metabolic defect that led to the accumulation of toxic levels of phenylalanine, an elevation that could largely be averted by adopting a low-phenylalanine diet, is an early example. Some cases of what was thought to be Sudden Infant Death Syndrome, a diagnosis (...) used when no etiology is known, now appear to have been caused by metabolic defects in fatty acid oxidation and sodium channel defects. One of the tasks that has already been undertaken by the public health sector is to ensure that genomic information is incorporated into clinical care when the robusmess of findings and their clinical utility have been well defined. (shrink)

An implicit rationale for ethics in medical schools is that there is a perceived need to teach students how not to think and how not to act, if they are to avoid a lawsuit or being struck off by the GMC. However, the imperative to keep within the law and professional guidance focuses attention on risks to patients that can land a doctor in trouble, rather than what it means to treat a patient humanely or well. In this paper I (...) explore the gap between learning how not to think and act as a doctor, and learning to be reflective and responsive to patients as fellow human beings. This gap is exposed by the difference between a GMC web resource for doctors, and a detailed ethical discussion by Gawande in his book Complications. The latter raises fundamental questions of meaning, and exemplifies an approach to ethical thinking as the appropriate management of doubt that, according to the argument of this paper, is of utmost importance for doctors. (shrink)

In March 1996, the General Accounting Office (GAO) issued the reportScientific Research: Continued Vigilance Critical to Protecting Human Subjects.It stated that “an inherent conflict of interest exists when physician-researchers include their patients in research protocols. If the physicians do not clearly distinguish between research and treatment in their attempt to inform subjects, the possible benefits of a study can be overemphasized and the risks minimized.” The report also acknowledged that “the line between research and treatment is not always cleartoclinicians. Controversy (...) exists regarding whether certain medical procedures should be categorized as research.”This problem currently plagues gene transfer research. A few months prior to the GAO report, an ad hoc committee appointed by National Institutes of Health (NIH) Director Harold Varmus expressed similar concerns in its assessment of NIH investment in research on gene therapy. (shrink)

In March 1996, the General Accounting Office (GAO) issued the reportScientific Research: Continued Vigilance Critical to Protecting Human Subjects.It stated that “an inherent conflict of interest exists when physician-researchers include their patients in research protocols. If the physicians do not clearly distinguish between research and treatment in their attempt to inform subjects, the possible benefits of a study can be overemphasized and the risks minimized.” The report also acknowledged that “the line between research and treatment is not always cleartoclinicians. Controversy (...) exists regarding whether certain medical procedures should be categorized as research.”This problem currently plagues gene transfer research. A few months prior to the GAO report, an ad hoc committee appointed by National Institutes of Health (NIH) Director Harold Varmus expressed similar concerns in its assessment of NIH investment in research on gene therapy. (shrink)

Background: Obtaining patients’ informed consent is an ethical and legal obligation in healthcare practice. Whilst the law provides prescriptive rules and guidelines, ethical theories of autonomy provide moral foundations. Models of practice of consent, have been developed in the bioethical literature to assist in understanding and integrating the ethical theory of autonomy and legal obligations into the clinical process of obtaining a patient’s informed consent to treatment.Aims: To review four models of consent and analyse the way each model incorporates the (...) ethical meaning of autonomy and how, as a consequence, they might change the actual communicative process of obtaining informed consent within clinical contexts.Methods: An iceberg framework of consent is used to conceptualise how ethical theories of autonomy are positioned and underpin the above surface, and visible clinical communication, including associated legal guidelines and ethical rules. Each model of consent is critically reviewed from the perspective of how it might shape the process of informed consent.Results and discussion: All four models would alter the process of obtaining consent. Two models provide structure and guidelines for the content and timing of obtaining patients’ consent. The two other models rely on an attitudinal shift in clinicians. They provide ideas for consent by focusing on underlying values, attitudes and meaning associated with the ethical meaning of autonomy.Conclusions: The paper concludes that models of practice that explicitly incorporate the underlying ethical meaning of autonomy as their basis, provide less prescriptive, but more theoretically rich guidance for healthcare communicative practices. (shrink)

Given Kant's exceptionless moral prohibition on lying, one might suspect that he is committed to a similar prohibition on withholding diagnostic and prognostic information from patients. I confirm this suspicion by adapting arguments against therapeutic privilege from his arguments against lying. However, I show that all these arguments are importantly flawed and submit that they should be rejected. A more compelling Kantian take on informed consent and therapeutic privilege is achievable, I argue, by focusing on Kant's duty of beneficence, which (...) requires us to aim at furthering others’ ends. But I show that there are some cases in which furthering a patient's ends requires withholding material medical information from her. Although I concede that these cases are probably quite rare, I conclude that the best Kantian thinking agrees with that of therapeutic privilege's advocates. (shrink)

Medical practitioners are duty-bound to tell their patients the truth about their medical conditions, along with the risks and benefits of proposed treatments. Some patients, however, would rather not receive medical information. A recent response to this tension has been to argue that that the disclosure of medical information is not optional. As such, patients do not have permission to refuse medical information. In this paper I argue that, depending on the context, the disclosure of medical information can undermine the (...) patient’s ability to exercise her autonomy or have therapeutically detrimental effects. In the light of these insights I go on to develop a context-sensitive approach to medical disclosure. The advantage of this account is that it addresses concerns on both sides of the debate; whilst it acknowledges that patients do not have an exercisable ‘right not to know,’ it allows that in some cases medical information ought to be withheld. (shrink)

In medical practice, the doctrine of informed consent is generally understood to have priority over the medical practitioner’s duty of care to her patient. A common consequentialist argument for the prioritisation of informed consent above the duty of care involves the claim that respect for a patient’s free choice is the best way of protecting that patient’s best interests; since the patient has a special expertise over her values and preferences regarding non-medical goods she is ideally placed to make a (...) decision that will protect her interests. In this paper I argue against two consequentialist justifications for a blanket prioritisation of informed consent over the duty of care by considering cases in which patients have imperfect access to their overall best interests. Furthermore, I argue that there are cases where the mere presentation of choice under the doctrine of informed consent is detrimental to patient best interests. I end the paper by considering more nuanced approaches to resolving the conflict between informed consent and the duty of care and consider the option of permitting patients to waive informed consent. (shrink)

Too many patients are injured in the course of care. Clinicians may mistakenly cause new harm to a patient or fail to take established steps to improve the presenting condition. Medical institutions within which they work may lack mechanisms to reduce errors or prevent them from harming patients. Many, perhaps even most, injuries are preventable, probably numbering in the hundreds of thousands a year for hospital care alone. Long ignored by medical practitioners and health-care payers and little appreciated by the (...) public, the problem of medical injury is finally receiving high-level policy attention. Much credit goes to the Institute of Medicine for its landmark report of November 1999, which marshaled the evidence about medical injuries and highlighted new approaches to systematic improvement of safety within systems of care. (shrink)

Too many patients are injured in the course of care. Clinicians may mistakenly cause new harm to a patient or fail to take established steps to improve the presenting condition. Medical institutions within which they work may lack mechanisms to reduce errors or prevent them from harming patients. Many, perhaps even most, injuries are preventable, probably numbering in the hundreds of thousands a year for hospital care alone. Long ignored by medical practitioners and health-care payers and little appreciated by the (...) public, the problem of medical injury is finally receiving high-level policy attention. Much credit goes to the Institute of Medicine for its landmark report of November 1999, which marshaled the evidence about medical injuries and highlighted new approaches to systematic improvement of safety within systems of care. (shrink)

Too many patients are injured in the course of medical care. This truth is as distressing now as it was four years ago when it began an article in this journal’s last similar symposium. Many or most injuries seem preventable. Yet today’s systems of care and of oversight of care too often fail to prevent them, despite generations of increasing legal intervention. Few injuries are litigated, even fewer addressed through medical peer review or state disciplinary authorities. The Institute of Medicine’s (...) landmark report To Err Is Human brought patient safety to national attention when released in late 1999. Half a decade later, significant reduction of injury remains a distant prospect, despite some apparent progress. (shrink)

Too many patients are injured in the course of medical care. This truth is as distressing now as it was four years ago when it began an article in this journal’s last similar symposium. Many or most injuries seem preventable. Yet today’s systems of care and of oversight of care too often fail to prevent them, despite generations of increasing legal intervention. Few injuries are litigated, even fewer addressed through medical peer review or state disciplinary authorities. The Institute of Medicine’s (...) landmark report To Err Is Human brought patient safety to national attention when released in late 1999. Half a decade later, significant reduction of injury remains a distant prospect, despite some apparent progress. (shrink)

Just why a patient should trust a particular healer isa question that has not been adequately explored inthe literature on healing. This ethnographiccase-report examines the healing performance of achiropractor and proposes that it contains fourintrinsic claims to trustworthiness: he claims to bea qualified and sincere healer who is inpossession of knowledge and techniques that derivetheir power from their truth content and whichempower him to make beneficial changes in thepatient. Taking each claim in turn I described thenature of the claim, how (...) it might be adequatelyvalidated, ways in which his healing performance mightvalidate it and how he might be assisted by thepatient, and how their actual validation may bedistorted by the healer and patient. It is suggestedthat while unusual in many regards, this unorthodoxhealing performance may be a foil by which toexamine other more orthodox healing performances. (shrink)

S. Matthew Liao's paper (2005) exemplifies what I characterize as the third stage in the lifecycle of bioethics, “bioethics as co-PI,” in which bioethics asserts a role in directing the biomedical...

Critically examining what most people take for granted is central to philosophical inquiry. Philosophers who accept positions on policy making commissions, tasks forces, or committees cannot, however, play the same uncompromisingly critical role in this capacity as they do in the classroom or in their personal research or writing. Still, philosophers have much to contribute to such bodies, and they can do so without compromising their integrity or betraying themselves as philosophers. Keywords: compromise, critical reflection, embryo research, integrity, organ transplantation, (...) policy development, Warnock Committee CiteULike Connotea Del.icio.us What's this? (shrink)

In this paper, we illustrate some serious difficulties involved in conveying information about uncertain risks and securing informed consent for risky interventions in a clinical setting. We argue that in order to secure informed consent for a medical intervention, physicians often need to do more than report a bare, numerical probability value. When probabilities are given, securing informed consent generally requires communicating how probability expressions are to be interpreted and communicating something about the quality and quantity of the evidence for (...) the probabilities reported. Patients may also require guidance on how probability claims may or may not be relevant to their decisions, and physicians should be ready to help patients understand these issues. (shrink)

For over 20 years the medical literature has carefully documented the undertreatment of all types of pain by physicians. During this same period, as the field of bioethics came of age, the phenomenon of undertreated pain received almost no attention from the bioethics literature. This article takes bioethicists to task for failing to recognize the undertreatment of pain as a major ethical, and not merely a clinical, failing of the medical profession. The nature and extent of the problem of undertreated (...) pain is examined, as well as possible reasons for its disregard by bioethicists. The factors contributing to undertreated pain in the clinical setting are considered, as well as the hazards posed by recent failures to address ethically questionable clinical practices. Finally, suggestions are offered for refocusing the attention of bioethicists to this significant problem. (shrink)

After expressing our gratitude to the commentators for their valuable analyses and assessments of Principles of Biomedical Ethics, we respond to several particular critiques raised by the commentators under the following rubrics: the compatibility of different sets of principles and rules; challenges to the principle of respect for autonomy; connecting principles to cases and resolving their conflicts; the value of and compatibility of virtues and principles; common morality theory; and moral status. We point to areas where we see common agreement (...) with our commentators and respond to their critical evaluations. (shrink)

The practice of obtaining informed consent has its history in, and gains its meaning from, medicine and biomedical research. Discussions of disclosure and justified nondisclosure have played a significant role throughout the history of medical ethics, but the term “informed consent” emerged only in the 1950s. Serious discussion of the meaning and ethics of informed consent began in medicine, research, law, and philosophy only around 1972.

Western culture has a few traditions of representing the human body – among them mortuary art (gisants), the freak show, the culture of the relics, renaissance art and pre-modern and modern anatomy. A historical analysis in the spirit of Norbert Elias is offered with regard to body – person relationship in anatomy. Modern anatomy is characterized by separating the story of the person from the story of the body, a strategy that is incompatible with the bio-psycho-social paradigm of clinical medicine. (...) The paper discusses different aspects of the above traditions and how they might bear on this conflict and on contemporary bioethics and bedside practice. (shrink)

In his deftly argued, “A Defense of Unqualified Confidentiality” (Kipnis 2006), Kenneth Kipnis challenges the received view that a physician's duty of confidentiality must be balanced against a dut...

Clozapine (Clozaril) is a new, powerful, costly anti-psychotic medicine, with a possible serious side effect (agranulocytosis) that entails weekly blood monitoring. In a three hundred bed state mental hospital that is allotted thirty clozapine slots (high costs effectively rationing this drug), a woman with schizophrenia responds minimally to this medication. Her attending physician wishes to withdraw the medicine and give it to another patient with schizophrenia on the ward who might have a better response. The woman's family threatens to make (...) a public outcry. Both the attending physician and the family ask the HEC for a consult. (shrink)

In June 1992, a national mail survey was directed to 204 state inpatient psychiatric institutions. This study was implemented following the 1992 Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requirement that hospitals put in place some means with which to address ethical issues. The goals of the study were: 1. to examine state mental hospital characteristics and their response to the JCAHO requirements; 2. to describe healthcare ethics committee (HEC) composition, function, and role; 3. to study patient and family (...) access to a HEC; and 4. to discover ethical issues most frequently addressed. The survey response rate was 71%. Of the 145 responders, 62 had HECs in place, and 53 were in the process of implementing HECs. There were no differences between JCAHO accredited institutions and non-accredited facilities with regard to having HECs. Physicians accounted for 22% of HEC membership, followed by nurses (15%), and administrators (12%). Twenty-six percent of facilities systematically notified patients about existence of the HEC; 71% of facilities had no patient request for HEC services in the last year. A patient's danger to others, and resuscitation policy were issues most frequently (23%) heard by HECs. (shrink)

(2003). The Ethics and Governance of Medical Research: What does regulation have to do with morality? New Review of Bioethics: Vol. 1, No. 1, pp. 41-58.

This essay lays the groundwork for a novel conception of autonomy that may be called “effective autonomy”—a conception designed to be genuinely action guiding in bioethics. As empirical psychology research on the heuristics and biases approach shows, decision making commonly fails to correspond to people’s desires because of the biases arising from bounded cognition. People who are classified as autonomous on contemporary philosophical accounts may fail to be effectively autonomous because their decisions are uncoupled from their autonomous desires. Accordingly, continuing (...) attempts to value patient autonomy must go beyond existing philosophical conceptions of autonomy to consider the background conditions of human decision making. (shrink)

Uncertainty and affect are fundamental and interrelated aspects of the human condition. Uncertainty is often associated with negative affect, but in some circumstances it is associated with positive affect. In this paper, we review different explanations for the varying relationship between uncertainty and affect. We identify “mental simulation” as a key process that links uncertainty to affective states. We suggest that people have a propensity to simulate negative outcomes, which results in a propensity towards negative affective responses to uncertainty. We (...) also propose the existence of several important moderators of this process, including context and individual differences such as uncertainty tolerance, as well as emotion regulation strategies. Finally, we highlight important knowledge gaps and promising areas for future research, both empirical and conceptual, to further elucidate the relationship between uncertainty and affect. (shrink)