The last twenty-five years of published literature and curriculum development in bioethics suggest that the field enjoys a successful and stable marriage to philosophical ethical theory. However, the next twenty-five years could be very different. I believe the marriage is troubled. Divorce is conceivable and perhaps likely. The most philosophical parts of bioethics may retreat to philosophy departments, while bioethics continues on its current course toward a more interdisciplinary and practical field.I make no presumption that bioethics is integrally linked to (...) philosophical ethical theory. Indeed, I assume that the connection is contingent and fragile. Many individuals in law, theological ethics, political theory, the social and behavioral sciences, and the health professions carefully address mainstream issues of bioethics without finding ethical theory essential or breathtakingly attractive. This is not surprising. Moral philosophers have traditionally formulated theories of the right, the good, and the virtuous in the most general terms. (shrink)

The first section of this paper asks why the notion of consensus has recently come to the fore in the medical humanities, and suggests that the answer is a function of growing technological and professional complexity. The next two sections examine the concept of consensus analytically, citing some of the recent philosophical literature. The fourth section looks at committee deliberations and their desirable outcomes, and questions the degree to which consensus serves those outcomes. In the fifth and last section it (...) is suggested that if I am to subscribe to a consensual outcome responsibly I must be personally committed to it, and that this requires a form of knowledge I call ‘fiduciary’, in this case knowledge of the competence and trustworthiness of other participants in deliberation whose expertise may have influenced my agreement. (shrink)

Philosophers, particularly moral philosophers, are increasingly being involved in public decision‐making in areas which are seen to raise ethical issues. For example, Dame Mary Warnock chaired the ‘Committee of Inquiry into Human Fertilization and Embryology’ in the UK in 1982–4; the Philosophy Department at Auckland was commissioned by the Auckland Regional Authority to report on the ethical aspects of fluoridating the public water supply in 1990; and many of us are serving on ethics committees of various sorts. Not only are (...) philosophers actually being called on or consulted, but many of us would argue that a philosophical contribution in such areas is essential.The involvement of moral philosophers in public policy decisions raises a question of professional ethics, viz, what role should a philosopher's own moral perspective or judgements play in the advice s/he gives, or contribution s/he makes, to public decision‐making on ethical issues. Like most problems in professional ethics, this prompts reflection on the nature of the profession, and in particular on the expertise we take moral philosophy to offer. It also prompts reflection on how processes of public decision making in ethically problematic areas should be understood. I explore these issues in this paper. (shrink)

There have been two parallel views regarding the role of voting in deliberation. The first is that deliberation before the fabrication of balloting was completely devoid of voting. The second is that voting is, not just part of deliberation, but is standard to deliberation. I argue in this article that neither of these views is correct. Implicit voting has always existed across time and space but only as a last resort in the event of a failure of natural unanimity. What (...) is relatively modern is the establishment of what I call explicit voting, namely, balloting, outside deliberation and often without deliberation. I also distinguish between natural and artificial unanimities, and clarify that artificial unanimities are products of implicit voting. I demonstrate these clarifications with some examples of deliberation. I deploy these clarifications to rid a certain debate of confusion regarding the precise role of voting in consensual deliberation. (shrink)

Public bioethics bodies are used internationally as institutions with the declared aims of facilitating societal debate and providing policy advice in certain areas of scientific inquiry raising questions of values and legitimate science. In the United States, bioethical experts in these institutions use the language of consensus building to justify and define the outcome of the enterprise. However, the implications of public bioethics at science-policy boundaries are underexamined. Political interest in such bodies continues while their influence on societal consensus, public (...) debate, and science policy remains ambiguous. This article presents a theoretical discussion of public bioethics bodies as boundary organizations and examines them in terms of relationship to the moral and cognitive authority of science and other forms of expertise, mechanisms for public participation in controversial science policy, and the deployment of consensus models. The theoretical discussion is examined in the case of the U.S. Human Embryo Research Panel. (shrink)

Roughly 80,000 U.S. prisoners are held in solitary confinement at any given time. A significant body of research shows that solitary confinement has severe, long-term effects, and the United Nations has condemned the practice of solitary confinement as torture. For years, prisoners have been organizing hunger strikes in order to protest solitary confinement. But such action is not without consequences, and some inmates have suffered serious injury or death. The question I raise in this paper is whether we ought to (...) force-feed hunger striking prisoners when serious harm is imminent. Both the World Medical Association and the American Medical Association have denounced the practice of force-feeding prisoners on hunger strike, and yet, the practice is common. Such prevalence is likely a result of the tension between the person-as-patient and person-as-prisoner and cannot easily be resolved. Instead, we must take seriously the complaint that solitary confinement is inhumane and avoid placing health professionals in the position where they must choose to force-feed the prisoner against his will or not. I argue that a conventional bioethics debate centering on polarizing principles of prisoner autonomy and a duty-to-protect the prisoner from harm is an inadequate framework for this complex issue. Instead, we must examine the prisoner’s intent and his right to freedom of speech. I argue that when the prisoner’s intent is to raise awareness and communicate with others, his hunger strike is a form of speech. Protest-as-speech is constitutionally protected—even for prisoners—and remains a minimum ethical obligation for society to uphold. (shrink)

In his proposal for a democracy by consensus, Wiredu argued that deliberation is an activity that depends solely on the logical persuasiveness of ideas. Emmanuel Chukwudi Eze and I had objected to this view of deliberation. Bernard Matolino has responded separately to Eze and me by sticking to Wiredu’s position that deliberation is a purely rational activity. In this article, I support my earlier claim that persuasion (and hence deliberation) is not an entirely logical activity, and our concern as human (...) beings is to recognize the influence of non-rational factors, for the purpose of minimizing the role of these non-rational factors. My general aim here is to explore the implications of a counterfactual situation in which we assume that deliberation is a purely rational activity, and these implications are unpalatable even to proponents of deliberation as a purely rational activity. My conclusion is that it is only by recognizing the role of non-rational factors in deliberation that we are driven to institute mechanisms to ensure that logic dominates over non-rational factors as much as practicable in either persuading or in being persuaded. Assuming that deliberation is a purely rational activity, on the other hand, forestalls any measures and allows non-rational influences to fester undeterred. (shrink)

In den USA haben sich im Wesentlichen drei verschiedene Organisationsformen klinischer Ethikberatung entwickelt: der einzelne Berater, das große Komitee und das Beratungsteam teilweise mit Rückbindung an ein größeres Komitee. Bislang gibt es jedoch weder empirische Daten noch ein Ergebnis der anfänglichen theoretischen Diskussion, ob es ein favorisiertes Modell für die klinische Ethikberatung geben sollte und welches dieses sei. Dieser Artikel argumentiert, dass die Vorzüge, Nachteile und die Erfolgsfaktoren der verschiedenen Organisationsformen in Abhängigkeit von der Zielsetzung klinischer Ethikdienste (KED) bewertet werden (...) müssen. Diese Zielsetzung kann auf einem Spektrum vom „Patientenanwalt“ bis zum „Gewissen der Institution“ angesiedelt sein. Die Zielsetzung bestimmt dabei Aufgabenschwerpunkte, Zusammensetzung, die favorisierte Organisationsform und wünschenswerte Standards. Die Untersuchung stützt sich zum einen auf die Analyse von Interviews mit fünf Vorsitzenden klinischer Ethikkomitees von Harvard Lehrkrankenhäusern in Boston, die jeweils etwa 20 Jahre Erfahrung in klinischer Ethikberatung mit den drei unterschiedlichen Modellen gemacht haben. Zum anderen basiert sie auf der Rezeption der Literatur und empirischen Studien zu KEDs in den USA und Deutschland. Insgesamt scheint das Konsilteam mit Rückbindung an ein Komitee am besten geeignet, die Behandlung einzelner Patienten und das ethische Bewusstsein einer ganzen Organisation zu verbessern. Es vereint die Vorteile der anderen beiden Modelle auf sich, ohne unter deren Schwächen zu leiden. (shrink)

A growing body of research has demonstrated significant heterogeneity of hospital ethics committee (HEC) size, membership and training requirements, length of appointment, institutional support, clinical and policy roles, and predictors of self identified success. Because these studies have focused on HECs at a single point in time, however, little is known about how the composition of HECs changes over time and what impact these changes have on committee utilization. The current study presents 20 years of data on the evolution of (...) the Massachusetts General Hospital HEC. Between 1993 and 2012, the average number of committee members per year was 38 ± 3 and the average length of membership was 4.8 ± 0.4 years. During that time, the committee performed 934 consults, averaging 47 ± 3 per year. Attendance rates fell from 61.5 to 23.8 % over the study period and were inversely correlated with the total number of members. Between 1993 and 2012, the committee saw substantial growth in the diversity of the professional backgrounds of its members. Multivariate analysis, however, suggests that substantial changes in committee composition did not impact its utilization and that other factors are more likely to explain fluctuations in consultation volume. (shrink)

L’argument de base de cet article est que le débat consensuel n’a pas été une notion très significative jusqu’à présent parce que le consensus n’a pas été étudié de manière approfondie en tant que concept et que la délibération n’a pas été étudiée précisément en termes de sa propension à parvenir à un accord commun. En particulier, la délibération et les problèmes qui en découlent n’ont pas été classées en plusieurs niveaux afin d’exposer les différents défis qui se posent lorsque (...) l’on tente de parvenir à un accord et les types d’approches délibératives impliquées dans chaque catégorie. La présente recherche propose une telle catégorisation dans le but de clarifier davantage le débat. (shrink)

El Convenio de Oviedo, de 1997, demuestra la dificultad de llegar a acuerdos internacionales sobre cómo regular la investigación biomédica, en especial los límites de la investigación con embriones. Algunos temas de Bioética muestran la pluralidad de doctrinas y de sistemas morales; es más, pueden indicar el final de la era del consenso. El final de la pax bioetica, que tanto significó para el éxito de la disciplina a lo largo de tres décadas. Tender puentes, forjar consenso ha sido, en (...) efecto, una de las contribuciones más valiosas del discurso bioético y de los nuevos expertos en Bioética. Desde los años setenta, los principios del Liberalismo y las actitudes pragmáticas han sido el núcleo de su ideología, un tipo de consenso «americano» para poner fronteras a las ideologías políticas o radicales. Sin embargo, la actual agenda ampliada de la Bioética, así su expansión internacional, están minando el consenso básico. Un giro más político de la Bioética podría, tal vez, ofrecer algunos acuerdos sobre temas específicos. Este tipo de consenso estaría también más cerca de los intereses de los ciudadanos, así como del nuevo contexto, global y social: sería un consenso «republicano», por así decirlo. El artículo analiza la evolución desde la etapa del consenso –tender puentes, principios comunes, procedimientos «no densos»– hacia los acuerdos plurales –contextuales, «densos»–, teniendo en cuenta la pluralidad de los valores morales y de las fronteras culturales. (shrink)

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)

In den USA haben sich im Wesentlichen drei verschiedene Organisationsformen klinischer Ethikberatung entwickelt: der einzelne Berater, das große Komitee und das Beratungsteam teilweise mit Rückbindung an ein größeres Komitee. Bislang gibt es jedoch weder empirische Daten noch ein Ergebnis der anfänglichen theoretischen Diskussion, ob es ein favorisiertes Modell für die klinische Ethikberatung geben sollte und welches dieses sei. Dieser Artikel argumentiert, dass die Vorzüge, Nachteile und die Erfolgsfaktoren der verschiedenen Organisationsformen in Abhängigkeit von der Zielsetzung klinischer Ethikdienste (KED) bewertet werden (...) müssen. Diese Zielsetzung kann auf einem Spektrum vom „Patientenanwalt“ bis zum „Gewissen der Institution“ angesiedelt sein. Die Zielsetzung bestimmt dabei Aufgabenschwerpunkte, Zusammensetzung, die favorisierte Organisationsform und wünschenswerte Standards. Die Untersuchung stützt sich zum einen auf die Analyse von Interviews mit fünf Vorsitzenden klinischer Ethikkomitees von Harvard Lehrkrankenhäusern in Boston, die jeweils etwa 20 Jahre Erfahrung in klinischer Ethikberatung mit den drei unterschiedlichen Modellen gemacht haben. Zum anderen basiert sie auf der Rezeption der Literatur und empirischen Studien zu KEDs in den USA und Deutschland. Insgesamt scheint das Konsilteam mit Rückbindung an ein Komitee am besten geeignet, die Behandlung einzelner Patienten und das ethische Bewusstsein einer ganzen Organisation zu verbessern. Es vereint die Vorteile der anderen beiden Modelle auf sich, ohne unter deren Schwächen zu leiden. (shrink)

So much philosophical theory is irrelevant for the practice of ethics! How many wasted volumes of tortuous arguments and counterarguments have been written in search of an elusive theory of ethics that could be applied deductively, without modification, to produce “correct” answers under all circumstances to any ethical problem? The practice of ethics is much closer to the common sense casuistry approach outlined by Jonsen and Toulmin, in which we work from. intuitively grasped, paradigm, cases by way of analogy to (...) provide presumptive answers to more complex problems. Alasdair Maclntyre argued however that we cannot trust such individualistic intuitive judgements. Thus we should start by looking at his critique of modern ethics. (shrink)