What is informed consent in medicine? For more than a generation, this deceptively simple question has vexed the law, discomfited medicine, and generated much inspired, provocative, and even contentious commentary.The question has also spawned several lawsuits. On one side stand patients who claim that, at the time of consent, they were ignorant of a particular risk; who state that, with more or different information, they would have chosen a different treatment; and who argue that, because of an adverse outcome, they (...) now deserve remuneration. On the other side, doctors uneasily watch the lengthening list of suits. Some, troubled by the law's expectations, have reacted by variously describing informed consent as a myth, a fiction, an unattainable goal, or a snare to entrap physicians. They point to the legal commentary condemning informed consent law as ill-defined, diffuse, and fraught with inconsistency, hazy at its best and virtually indecipherable to physicians at its worst: and lacking a fair standard to determine when a patient has sufficient knowledge to give effective consent. (shrink)

At the center of medical morality is the healing relationship. It is defined by three phenomena: the fact of illness, the act of profession, and the act of medicine. The first puts the patient in a vulnerable and dependent position; it results in an unequal relationship. The second implies a promise to help. The third involves those actions that will lead to a medically competent healing decision. But it must also be good for the patient in the fullest possible sense. (...) The physician cannot fully heal without giving the patient an understanding of alternatives such that he or she can freely arrive—together with the physician—at a decision in keeping with his or her personal morality and values. In today's pluralistic society, universal agreement on moral issues between physicians and patients is no longer possible. Nevertheless, a reconstruction of professional ethics based on a new appreciation of what makes for a true healing relationship between patient and physician is both possible and necessary. (shrink)

Virtue ethics attempts to identify certain commonly agreed-upon dispositions to act in certain ways, dispositions that would be accepted as ‘good’ by those affected, and to locate the goodness or badness of an act internal to the agent. Basically, virtue ethics is said to date back to Aristotle, but as Alisdair MacIntyre has pointed out, the whole idea of ‘virtue ethics’ would have been unintelligible in Greek philosophy for “a virtue was an excellence and ethics concerned excellence of character; all (...) ethics was virtue ethics.” Virtue ethics as a method to approach problems in medical ethics is said by some to lend itself to working through cases at the bedside or, at least, is better than the conventional method of handling ethical problems. In this paper I want to explore some of the shortcomings of this approach, examine other traditional approaches, indicate some of their limitations, and suggest a different conceptualization of the approach. (shrink)

The clinical ethics propounded by Richard Zaner is unique. Partly because of his phenomenological orientation and partly because of his own daily practice as a clinical ethicist in a large university hospital, Zaner focuses on the particular concrete situations in which patients and their families confront illness and injury and struggle toward workable ways for dealing with them. He locates ethical reality in the clinical encounter. This encounter encompasses not only patient and physician but also the patients family and friends (...) and indeed the entire lifeworld in which the patient is still striving to live. In order to illuminate the central moral constituents of such human predicaments, Zaner discusses the often-overlooked features of disruption and crisis, the changed self, the patients dependence and the physicians power, the violation of personal boundaries and their necessary reconfiguring, and the art of listening. (shrink)

The article offers an approach to inquiry about, the foundation of medical ethics by addressing three areas of conceptual presupposition basic to medical ethical theory. First, medical ethics must presuppose a view about the nature of medicine. it is argued that the view required by a cogent medical morality entails that medicine be seen both as a healing relationship and as a practical art. Three ways in which medicine inherently involves values and valuation are presented as important, i.e., in being (...) aimed at the good of health, in being a cognitive art evaluating towards that good, and as a manifestation of a virtuous disposition concerning that good. Finally, a value ontology drawn from these considerations is seen as necessarily underlying medical ethics. A set of three such basic values are promoted as crucial: the value of health; the value of the individual patient; and the value of altruism that mediates the class of potential patients. (shrink)

In this paper I attempt to show that the doctrine of informed consent, as practiced in the relationships between physicians and patients, often does not fulfill its main purpose, i.e., it does not safeguard the interests, rights, and dignity of patients. This happens because of clinicians' skepticism about the existence of the right to informed consent, patients' disinclination to make decisions, the current nature of health care, and the absence of clear guidelines about implementing informed consent. In the context of (...) this paper informed consent refers to the principle of respect for autonomy. (shrink)

Society and social structures play an important role in the formation and evaluation of concepts and practices in clinical ethics. This is evident in the ways the authors in this issue explore a wide range of arguments and concepts in clinical ethics including moral distress and conscience based practice, phenomenological interview techniques and gender dysphoria, continuous deep sedation (CDS) at the end of life, the notion of patient expertise, ethically permissible medical billing practices, the notion of selfhood and patient centered (...) care in dementia patients, and the definition of minimal risk as used in research regulations. (shrink)

Volume 20, Issue 6, June 2020, Page 40-42.

Volume 20, Issue 6, June 2020, Page 42-44.

In this paper, I introduce the ideas to be discussed in the articles of this journal with reference to an imaginary case involving a pregnant woman declared dead on the basis of neurological criteria. I highlight the fact that although these ideas have proved useful for advancing certain claims in bioethical debates, their implications are not always well understood and may complicate our arguments. The ideas to be discussed are an ethic internal to the profession of medicine; the difference between (...) killing and letting die; the organism as a whole; and the “lives” and interests of the dead. (shrink)

For at least the past several decades, medicine has been embroiled in a crisis concerning the nature of its professionalism. The fundamental questions that drive this ongoing crisis are primarily three. First, what is the nature of medical professionalism? Second, who are medical professionals? Third, what does medicine or these professionals profess or promise? In this paper, the professionalism crisis vis-à-vis these questions is examined and analyzed chiefly in terms of both Francis Peabody’s and Edmund Pellegrino’s writings. Based on their (...) writings, I introduce a conceptual framework for professionalism to address the crisis. In addition, I contend that to address the professionalism crisis adequately, medicine’s position within an evolving health care network must also be considered. To that end, I first discuss the genesis of the crisis in terms of the Flexner Report and especially Peabody’s response to it. Next, I explore how the crisis intensified during the twentieth century, particularly in terms of medicine’s ultimate scientification and eventual commercialization, and how Pellegrino reacted to this. I then propose a health care professionalism cycle and a care-competence cycle to provide a conceptual framework for addressing the crisis. I conclude that medicine’s position is no longer as the center of health care but rather as another node within a wider evolving health care network. And the resolution of medicine’s professionalism crisis depends on medicine’s positioning and defining itself in terms of the professionalism for each of the other professions within the health care network. (shrink)

Human rights have increasingly been put forward as an important framework for bioethics. In this paper, it is argued that human rights offer a potentially fruitful approach to understanding the notion of Respect for Persons in bioethics. The idea that we are owed a certain kind of respect as persons is relatively common, but also quite often understood in terms of respecting people’s autonomous choices. Such accounts do however risk being too narrow, reducing some human beings to a second-class moral (...) status. This paper puts forward a political approach to our standing as persons and a strongly pluralistic account of human rights that lays the ground for a more broadly applicable conception of Respect for Persons. It is further argued that this model also provides an example of a more general approach to philosophical ethics, an approach which is here called taxonomical pluralism. When it comes to Respect for Persons specifically, this principle is developed in terms of five distinct core concerns. (shrink)

Like most EM physicians presented with a wide assortment of patients I've never seen before, will probably never see again, and cannot schedule for a more convenient return visit when there are not three ambulances pulling up to the door, I sometimes get a bit cranky when I interview a patient who has registered for a less‐than‐valid “emergency.” As a resident in Mel Konner's Becoming a Doctor put it, “Low back pain? Low fucking back pain? You're waking me up for (...) low fucking back pain?” Although I ceased a long time ago to ask, “Why now?”—you almost never get an answer that is satisfying—I still think it. Often, I am sad to say. Perhaps it is a result of the obvious forces of callousness born of distance born of training and of stress. Again, Konner captures it well: “It is obvious … that the stress of clinical training alienates the doctor from the patient, that in a real sense the patient becomes the enemy. … At first I believed that this was an inadvertent and unfortunate concomitant of medical training, but I now think that it is intrinsic. Not only stress and sleeplessness but the sense of the patient as the cause of one's distress contributes to the doctor's detachment.” Such detachment can blinker our eyes from seeing why patients come to the emergency room and prevent our ears from hearing. (shrink)

What is informed consent in medicine? For more than a generation, this deceptively simple question has vexed the law, discomfited medicine, and generated much inspired, provocative, and even contentious commentary.The question has also spawned several lawsuits. On one side stand patients who claim that, at the time of consent, they were ignorant of a particular risk; who state that, with more or different information, they would have chosen a different treatment; and who argue that, because of an adverse outcome, they (...) now deserve remuneration. On the other side, doctors uneasily watch the lengthening list of suits. Some, troubled by the law's expectations, have reacted by variously describing informed consent as a myth, a fiction, an unattainable goal, or a snare to entrap physicians. They point to the legal commentary condemning informed consent law as ill-defined, diffuse, and fraught with inconsistency, hazy at its best and virtually indecipherable to physicians at its worst: and lacking a fair standard to determine when a patient has sufficient knowledge to give effective consent. (shrink)

At the center of medical morality is the healing relationship. It is defined by three phenomena: the fact of illness, the act of profession, and the act of medicine. The first puts the patient in a vulnerable and dependent position; it results in an unequal relationship. The second implies a promise to help. The third involves those actions that will lead to a medically competent healing decision. But it must also be good for the patient in the fullest possible sense. (...) The physician cannot fully heal without giving the patient an understanding of alternatives such that he or she can freely arrive—together with the physician—at a decision in keeping with his or her personal morality and values. In today's pluralistic society, universal agreement on moral issues between physicians and patients is no longer possible. Nevertheless, a reconstruction of professional ethics based on a new appreciation of what makes for a true healing relationship between patient and physician is both possible and necessary. (shrink)

The particular situation of the French administrative detention center medical units appears to be an exemplary case to study the difficulties facing medical practice. Indeed, the starting point of our inquiry was an amazing observation that needed to be addressed and understood: why are professional interpreters so seldom requested in ADC medical units, where one would expect that they would be “naturally” present? Aiming to fully explore the meanings of the “absent interpreter”, this article takes into account the possible meanings (...) of this situation: the recourse to professional interpreters in France is far from expected given cumulative evidence of its benefits; perceptions of illegal immigrants and medical habitus itself may both hamper the use of a third party; the ADCs are a very stressful place for healthcare professionals, with conflicting missions, political issues enmeshed with medical goals, and heavy affective burden that may lead to self-protection. Silencing voices of suffering others might be seen as the hidden indecent truth of the “absent interpreter”. These reflections open a window to a larger issue with regard to the full range of medicine: what are the place, the role and the function of patient’s words and narratives in contemporary medicine? The highly invested somatic perspective and its political corollary giving primacy to bare life harbor potential risks of obscuring speeches and undervaluing narratives. (shrink)

The use of organs obtained from executed prisoners in China has recently been condemned by every major transplant organization. The government of the People's Republic of China has also recently made it illegal to provide transplant organs from executed prisoners to foreigners transplant tourists. Nevertheless, the extreme shortage of transplant organs in the U.S. continues to make organ transplantation in China an appealing option for some patients with end-stage disease. Their choice of traveling to China for an organ leaves U.S. (...) transplant programs with decisions about how to respond to the needs of patients who return after transplantation. By discussing two cases that raised this dilemma, we argue for upholding medicine's commitments to traditional principles of beneficence and nonjudgmental regard in sorting out the policies that a transplant program should adopt. We also explain how position statements that aim for the high ground of moral purity fail to give appropriate weight to the needs and suffering of present and future patients in the U.S. and in China. (shrink)

Modern medicine faces fundamental challenges that various approaches to the philosophy of medicine have tried to address. One of these approaches is based on the ancient concept of phronesis. This paper investigates whether this concept can be used as a moral basis for the challenges facing modern medicine and, in particular, analyses phronesis as it is applied in the works of Pellegrino and Thomasma. It scrutinises some difficulties with a phronesis-based theory, specifically, how it presupposes a moral community of professionals. (...) It is argued that Pellegrino and Thomasma's concept of phronesis corresponds to a Hippocratic concept of t�chn�, and that this latter concept seems to address many of the challenging issues Pellegrino and Thomasma also address. Thus, if modern medicine is to find its philosophical model in ancient concepts, it appears that the Hippocratic t�chn� is closer to the ancient concept of medicine than the Aristotelian phronesis, and that it might avoid many of the pitfalls of a phronesis-based approach. (shrink)

It is often said that because physicians and other healthcare professionals frequently play a critical role in determining the fate of their patients, they ought if at all possible to be their patient's friend. The relationship of necessity is intimate: physicians have knowledge of their patients' histories and of their bodies which under other circumstances would be reserved to the most intimate of friends, and physicians and patients meet under more or less critical situations. In this paper, I briefly examine (...) the role of the physician as “friend,” an Issue to be much more extensively explored In a book In preparation. (shrink)

The professional regulatory system known as medical ethics has been one of the most visionary and socially valuable creations of the medical profession. Its beneficial influence has extended beyond physician/patient relations, to the shaping of many key humanistic and egalitarian features of the world’s legal and political institutions. The continued existence of medical ethics as a professionally influential normative system, however, is being challenged by international human rights. The UNESCO Universal Declaration on Bioethics and Human Rights, is likely to be (...) an important point of intersection in this process. (shrink)

While there has been much discussion about the role of oaths in medical ethics, this discussion has previously centered on the content of various oaths. Little conceptual work has been done to clarify what an oath is, or to show how an oath differs from a promise or a code of ethics, or to explore what general role oath-taking by physicians might play in medical ethics. Oaths, like promises, are performative utterances. But oaths are generally characterized by their greater moral (...) weight compared with promises, their public character, their validation by transcendent appeal, the involvement of the personhood of the swearer, the prescription of consequences for failure to uphold their contents, the generality of the scope of their contents, the prolonged time frame of the commitment, the fact that their moral force remains binding in spite of failures on the part of those to whom the swearer makes the commitment, and the fact that interpersonal fidelity is the moral hallmark of the commitment of the swearer. Oaths are also distinct from codes. Codes are collections of specific moral rules. Codes are not performative utterances. They do not commit future intentions and do not involve the personhood of the one enjoined by the code. Recent attacks on oath-taking by physicians are discussed. Two arguments in favor of oath-taking are presented: one on the basis of the nature of medicine as a profession and the other on the basis of rule-utilitarian considerations. No attempt is made to define which oath a physician should swear. (shrink)

This paper argues that we have wrongly and not for the patient’s benefit made a form of stark autonomy our highest value which allows physicians to slip out from under their basic duty which has always been to pursue a particular patient’s good. In general – I shall argue – it is the patient’s right to select his or her own goals and the physician’s duty to inform the patient of the feasibility of that goal and of the means needed (...) to attain it. If the goal is not one that is possible, the patient, with the physician and family, must select a feasible goal and then discuss the costs/benefits of various approaches. The physician should take a leading role in helping the patient select the goal. I argue that to simply present a laundry list of means and insist that patients choose for themselves is not only abandoning patients to their autonomy but is, in fact, a crass form of violating the patient’s autonomy. Freely choosing not to choose is a choice a patient with decisional capacity is entitled to make and one that needs to be respected. (shrink)

:Although recent literature on professionalism in healthcare abounds in recommended character traits, attitudes, or behaviors, with a few exceptions, the recommendations are untethered to any serious consideration of the contours and ethical demands of the healing relationship. This article offers an approach based on the professional’s commitment to trustworthiness in response to the vulnerability of those seeking professional help. Because our willingness and ability to trust health professionals or healthcare institutions are affected by our personality, culture, race, age, prior experiences (...) with illness and healthcare, and socioeconomic and political circumstances—“the social determinants of trust”—the attitudes and behaviors that actually do gain trust are patient and context specific. Therefore, in addition to the commitment to cultivating attitudes and behaviors that embody trustworthiness, professionalism also includes the commitment to actually gaining a patient’s or family’s trust by learning, through individualized dialogue, which conditions would win their justified trust, given their particular history and social situation. (shrink)

At the center of medical morality is the healing relationship. It is defined by three phenomena: the fact of illness, the act of profession, and the act of medicine. The first puts the patient in a vulnerable and dependent position; it results in an unequal relationship. The second implies a promise to help. The third involves those actions that will lead to a medically competent healing decision. But it must also be good for the patient in the fullest possible sense. (...) The physician cannot fully heal without giving the patient an understanding of alternatives such that he or she can freely arrive—together with the physician—at a decision in keeping with his or her personal morality and values. In today's pluralistic society, universal agreement on moral issues between physicians and patients is no longer possible. Nevertheless, a reconstruction of professional ethics based on a new appreciation of what makes for a true healing relationship between patient and physician is both possible and necessary. (shrink)

Physicians accept fallibility in technical matters as a condition of medical practice. When it comes to moral considerations, physicians are often loathe to act without a good deal more certitude and seem less willing to accept error. This article argues that ethics is intrinsic to medical decision making, that error is the inevitable risk of any action and that inaction carries even greater risk of error. Whether in the moral or the technical sphere, error must be accepted by physicians as (...) part of the learning process which informs and enriches future decisions. Moral virtue, it is concluded, resides more in the making of a decision and in the agony of making it than it does in the potentially fallible decision itself. (shrink)

For more than two decades, classes on “professionalism” have been the dominant platform for the non-technical socialization of medical students. It thus subsumes elements of previous foundation courses in bioethics and “medicine and society” in defining the appropriate relation between practitioners, patients, and society-at-large. Despite its importance, there is, however, no clear definition of what “professionalism” entails or the manner in which it serves various purported goals. This essay reviews, first, the historical role of the vocational practitioner in society, and (...) second, the introduction of “professionalism” as a newly constituted, core value in teaching. The structure of the paper is as an archaeology, a Foucauldian term for an investigation of seemingly separate but related antecedent contexts and ideas whose result is a perspective or point of view. The goal thus is an attempt to precisely locate “professionalism” within the greater history of medicine and its contemporary role in medical socialization. (shrink)

BackgroundPrevious empirical work among physicians has led us to propose that clinical practice is experienced by clinicians as an engagement-in-the-clinical-situation. In this study, we pursue our exploration of clinical practice ‘on its own terms’ by turning to the experience of patients.MethodsPhenomenological analysis of in-depth individual interviews with 8 patients.ResultsWe describe the patient experience as a set of three motifs: the shock on the realization of the illness, the chaos of the health care environment, and the anchor point provided by an (...) engaged physician. We draw on Heidegger’s notion of solicitude to show that patients are actively ascertaining the physician’s engagement in their care.ConclusionsThese findings lead us to question the classical “dual discourse” of medicine that offers a dichotomous account of clinical practice as the addition of care to cure, art to science, humanism to technique, and person to medical case. We found no such distinctions in our empirical investigation of clinical practice. Rather, in our synthesis, practice appears as a unitary experience. The physician’s solicitude for the patient entrains engagement in the clinical situation. Moreover, the solicitous, engaged physician constitutes an anchor point for the patient. (shrink)

Since the 1980’s, surrogacy has become a popular reproductive alternative for individuals experiencing infertility. The ethical and legal analyses of surrogacy have been rich and varied. Some bioethicists have charged the commercial surrogacy industry with the exploitation of global southern women or with the impermissible commodification of children and women’s reproductive capacities. Others have praised the potential for economic empowerment and bodily autonomy that surrogacy may accord to women. However, throughout these explorations of the ethics of surrogacy, comparatively little attention (...) has been paid to the moral status of a crucial actor: the fertility doctor. Without doctors willing to provide prenatal and postnatal care to surrogates and make use of assisted reproductive technologies (ARTs), commercial surrogacy would not take place. Yet, doctors’ involvement in surrogacy is far from morally neutral. In my thesis, I aim to explore what duties doctors have in the context of commercial surrogacy. To do so, I take up the framework of fiduciary obligation. I argue that doctors have fiduciary obligations to surrogates, and that these obligations shape if and when doctors can ethically facilitate surrogacy. My thesis is divided into four chapters. The first defends the view that the doctor-patient relationship is fiduciary in nature. The second chapter extends this view to the realm of commercial surrogacy, arguing that doctors also owe the surrogates they treat fiduciary obligations. The third chapter addresses a challenge posed by my view, namely that surrogacy seems to place doctors in positions where they constantly face conflicts of interest, and are therefore unable to uphold their fiduciary duty of loyalty to surrogates. I address this concern by arguing that conflicts of interest are not inherent in surrogacy, but that surrogacy arrangements must be substantially rethought in order to safeguard the doctor-surrogate fiduciary relationship. The final chapter considers the obligations doctors have to the children they help create through surrogacy and through assisted reproduction more generally. (shrink)

The papers in this volume are largely about research ethics and cover questions of consent, reproduction, pediatric research, ethical codes, and clinical relationships. Half the papers have this common aspect: they are conservative—in the sense of supporting the standard, prevailing, or popular view—but they shift the focus—supporting the standard views in terms of moral factors generally neglected by the literature. The volume provides a diverse set of papers for the reader: variously addressing abstract and concrete problems from within different philosophical (...) traditions. (shrink)

A purely deductive medical ethics cannot properly account for the varieties of circumstances which arise in medical practice. By contrast, a purely inductive medical ethics lacks sufficient guidance from ethical principles. In resolving ethical dilemmas in medicine, most often an appeal is made to middle-level axioms and methodological rules to mediate between theory and practice. I argue that this appeal must be augmented by considerations of context, such considerations, in effect, constituting a moral rule based on the social structure of (...) medical practice. A contextual grid is proposed which assists the process of weighing values in resolving cases. (shrink)

This paper throws some light on the nature of argumentation, its use and advantages, within the setting of doctor–patient interaction. It claims that argumentation can be used by doctors to offer patients reasons that work as ontological conditions for enhancing the decision making process, as well as to preserve the institutional nature of their relationship with patients. In support of these claims, selected arguments from real-life interactions are presented in the second part of the paper, and analysed by means of (...) a model of argumentation borrowed from classical rhetoric, and refined according to the modern orientation of the pragma-dialectic approach. (shrink)

This philosophical inquiry examines the nature of the technology of genetic predisposition testing and its relation to patients as whole persons. The bioethical principles of nonmaleficence, beneficence, autonomy and justice are judged insufficient to resolve issues associated with use. A new principle of ‘sustained being’, drawn from philosophical propositions of Pellegrino, is suggested. The new principle is suited to an evolving practice and is compatible with consequentialist, deontological and relational ethics theories. The notion of ‘taking care’ is related to nursing (...) in genetic health care to form a standard of conduct and a moral imperative to ‘safeguard being’. (shrink)

The present article proceeds from the observation that the therapeutic relationship is basically unequal. This inequality essentially concerns the respective situation of the patient and his or her doctor vis-à-vis medical knowledge. A strict professionalism guarantees that this inequality remains factual and without essential value. Yet, if both partners unreflectively allow affectivity excessively to intrude into their relationship, their behaviour may then be inspired by subconscious, rather than rational, motives. In that case, the unverifiable allegations of philanthropy or paternalism may (...) be used to rationalise a kind of 'medical sadism' which attempts to justify the will to humiliate the patient by means of the constraints inherent in medical care. The concept of ethical form is introduced as a non-verbal criterion of ethical reliability. It is mainly a way of training the will through the application of rationally justified rules of behaviour. In this context, it is suggested that an effort to remain constantly within the limits of professionalism represents a method of training for the achievement of some degree of ethical credibility in the therapeutic relationship. In the long term, such abstinence could constitute a sort of catharsis, and thereby help to reveal the non-rational motives in medical behaviour. Contrary to the belief prevailing in modern society, the established limits of medical knowledge are not so broad. The application of these limits would probably be the best method of preventing emotions from interfering undesirably in the therapeutic relationship. (shrink)

The programmatic thrust of Thomasma and Pellegrino [5] is clarified and underscored and is interpreted as an attempt to introduce a fixed point into the ethical dimension of medicine by specifying some regulative principles for the medical profession. Two important features of this type of enterprise are noted: on the one hand, it may lead the profession to distinguish between technically identical actions on the basis of the normative principles it produces, thus excluding some morally permissible actions as duties constitutive (...) of the art. It is argued that the formulation of the grounds for this ethic given by Thomasma and Pellegrino is insufficient. In order to speak to the clinical situation, medical ethics must not be based on merely the living human body alone, but on the patientqua person. (shrink)

Mere possession of generic professional credentials cannot be used as justification of necessary and sufficient skill to perform in a forensic role. Case examples are used to illustrate problems of both competence and quality that sometimes accompany mental health clinicians to the witness stand.