Physicians participate in several kinds of activities in their professional lives. Clinical care is the core function of the physician. Medical education is overwhelmingly oriented toward this func...

This paper aims to refute a common line of argument that it is immoral for physicians to engage in medical assistance in death (MAiD), i.e., the practices of euthanasia and physician-assisted suicide. The argument in question is based on the notion that participating in MAiD is contrary to the professional-role obligations of physicians, due to MAiD’s putative inconsistency with the ends of medicine. The paper describes several major flaws from which that argument suffers.

Fair allocation of scarce healthcare resources has been much studied within philosophy and bioethics, but analysis has focused on a narrow range of cases. The Covid-19 pandemic provided significant new challenges, making powerfully visible the extent to which health systems can be fragile, and how scarcities within crucial elements of interlinked care pathways can lead to cascading failures. Health system resilience, while previously a key topic in global health, can now be seen to be a vital concern in high-income countries (...) too. Unfortunately, mainstream philosophical approaches to the ethics of rationing and prioritisation provide little guidance for these new problems of scarcity. Indeed, the cascading failures were arguably exacerbated by earlier attempts to make health systems leaner and more efficient. This paper argues that health systems should move from simple and atomistic approaches to measuring effectiveness to approaches that are holistic both in focusing on performance at the level of the health system as a whole, and also in incorporating a wider range of ethical concerns in thinking about what makes a health system good. (shrink)

BackgroundVascular surgery offers a range of treatments to relieve pain and ulcerations, and to prevent sudden death by rupture of blood vessels. The surgical procedures involve risk of injury and harm, which increases with age and frailty leading to complex decision-making processes that raise ethical questions. However, how vascular surgeons negotiate these questions is scarcely studied. The aim was therefore to explore vascular surgeons’ moral reasoning of what ought to be done for the patient.MethodsQualitative, semi-structured interviews were conducted with 19 (...) vascular surgeons working at three Swedish university hospitals. Data were analysed according to systematic text condensation.ResultsThe surgeons’ moral reasoning about what ought to be done comprised a quest to relieve suffering and avoid harm by exploring what is reasonable to do for the patient. Exploring reasonableness included to shift one´s perspective from the vessels to the whole person, to balance patient’s conflicting needs and to place responsibility for right decision on one´s shoulders. The shift from blood vessels to the whole person implied gaining holistic knowledge in pondering of what is best, struggling with one´s authority for surgery through dialogue, and building relationship for mutual security. To balance patient’s conflicting needs implied weighing the patient’s independence and a sense of being whole against ease of suffering, respecting the patient’s will against protecting life and well-being, and weighing longer life against protecting the present well-being. Finally, to place responsibility on one´s shoulders was conveyed as an urge to remind oneself of the risk of complications, withholding one’s power of proficiency, and managing time during the illness course.ConclusionsThis study contributes to uncovering how moral reasoning is embodied in the vascular surgeons’ everyday clinical discourse as a tangible part of their patient care. The results underpin the significance of moral considerations in the assemblage of medical knowledge and technical skills to further understand vascular surgeons’ clinical practice. The clinical application of these results is the need of forums with sufficient possibilities for articulating these important moral considerations in everyday care. (shrink)

The medical profession contains five “spheres of morality”: clinical care, clinical research, scientific knowledge, population health, and the market. These distinct sets of normative commitments require physicians to act in different ways depending on the ends of the activity in question. For example, a physician-scientist emphasizes patients’ well-being in clinic, prioritizes the scientific method in lab, and seeks to maximize shareholder returns as a board member of a pharmaceutical firm. Physicians increasingly occupy multiple roles in healthcare and move between them (...) frequently, creating the possibility of conflict between the ethical obligations of their various roles. This paper examines the entire moral landscape of medicine through the lens of role morality. It develops a novel framework that helps physicians recognize how their moral commitments depend on the nature and context of the situation, clarifies ethical conflicts that physicians face, and concludes with ideas for resolving these conflicts. (shrink)

Medicine is increasingly subject to various forms of criticism. This paper focuses on dominant forms of criticism and offers a better account of their normative character. It is argued that together, these forms of criticism are comprehensive, raising questions about both medical science and medical practice. Furthermore, it is shown that these forms of criticism mainly rely on standards of evaluation that are assumed to be internal to medicine and converge on a broader question about the aim of medicine. Further (...) work making medicine’s internal norms explicit and determining the aim of medicine would not only help to clarify to what extent the criticism is justified, but also assist an informed deliberation about the future of medicine. To illustrate some of the general difficulties associated with such a task, the paper concludes by critically engaging Edmund Pellegrino’s account of the aim of medicine as well as the Hastings Center’s consensus report. (shrink)

That a standard of medical care must outline services that benefit the patient is relatively uncontroversial. However, one must determine how the practices outlined in a medical standard of care should benefit the patient. I will argue that practices outlined in a standard of medical care must not detract from the patient’s well-functioning and that clinicians can refuse to provide services that do. This paper, therefore, will advance the following two claims: (1) a standard of medical care must not cause (...) dysfunction, and (2) if a physician is medically rational to not provide some service which fails to meet the above condition (i.e. fails to be a standard of medical care), then she may refuse to do so. I then apply my thesis to the prescription of puberty blockers to children with gender dysphoria. (shrink)

Physicians frequently encounter situations in which their professional practice is intermingled with moral affordances stemming from other domains of the physician’s lifeworld, such as family and friends, or from general morality pertaining to all humans. This article offers a typology of moral conflicts ‘at the margins of professionalism’ as well as a new theoretical framework for dealing with them. We start out by arguing that established theories of professional ethics do not offer sufficient guidance in situations where professional ethics overlaps (...) with moral duties of other origins. Therefore, we introduce the moral theory developed by Christine M. Korsgaard, that centres around the concept of practical identity. We show how Korsgaard’s account offers a framework for interpreting different types of moral conflicts ‘at the margins of professionalism’ to provide either orientation for solving the conflict or an explanation for the emotional and moral burden involved in moral dilemmas. (shrink)

The clinical encounter begins with presentation of an illness experience; but throughout that encounter, something else is constructed from it – a symptom. The symptom is a particular interpretation of that experience, useful for certain purposes in particular contexts. The hermeneutics of medicine – the study of the interpretation of human experience in medical terms – has largely taken the process of symptom-construction to be transparent, focussing instead on how constellations of symptoms are interpreted as representative of particular conditions. This (...) paper examines the hermeneutical activity of symptom-construction more closely. I propose a fourfold account of the clinical function of symptoms: as theoretical entities; as tools for communication; as guides to palliative intervention; and as candidates for medical explanation or intervention. I also highlight roles they might play in illness experience. I use this framework to discuss four potential failures of symptom-interpretation: failure of symptom-type and symptom-token recognition; loss of the complete picture of illness experience through overwhelming emphasis on its symptomatic interpretation; and intersubjective feedback effects of symptom description altering the ill person’s own perceptions of their phenomenal experience. I conclude with some suggestions of potential remedies for failures in the process of symptom-construction. (shrink)

My question in the chapter is this: could (and should) the role of the physician be construed as that of a friend to the patient? I begin by briefly discussing the “friendship model” of the physician-patient relationship—according to which physicians and patients could, and perhaps should, be friends—as well as its history and limitations. Given these limitations, I focus on the more one-sided idea that the physician could, and perhaps should, be a friend to the patient (a “physician-qua-friend model” of (...) the physician-patient relationship). I show that given recent developments in our understanding of the physician-patient relationship, this idea is far from asinine. I then make the case that the most plausible conception of the physician-qua-friend model incorporates the following components: (a) a common goal, that is, one that physician and patient share; (b) certain forms of equality between physician and patient; (c) an ideal of a caring physician. Finally, I show how the model can be instantiated in a certain type of physician-patient interaction, namely, in physician-assisted dying. (shrink)

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

The goal of this paper is to propose a relational turn in healthcare professionalism, to improve the responsiveness of both healthcare professionals and organizations towards care of patients, but also professionals. To this end, it is important to stress the way in which difficult situations and vulnerability faced by professionals can have an impact on their performance of work. This article pursue two objectives. First, I focus on understanding and making visible shared vulnerability that arises in clinical settings from a (...) triple perspective: patient and family, health professionals, and institutions. Second, to address this challenge for professionalism, in this paper I articulate the term "relational centered-patient professionalism", which has two main axes. The relational approach means taking into account how the relationships among professionals, patients and institutions determine the constitution and evolution of those professional values. The focus on patient centered care is indispensable, because it is the ultimate goal pursued by the development of these professional values, and must always be at the center. (shrink)

According to Aristotle, the medical art aims at health, which is a virtue of the body, and does so in an unlimited way. Consequently, medicine does not determine the extent to which health should be pursued, and “mental health” falls under medicine only via pros hen predication. Because medicine is inherently oriented to its end, it produces health in accordance with its nature and disease contrary to its nature—even when disease is good for the patient. Aristotle’s politician understands that this (...) inherent orientation can be systematically distorted, and so would see the need for something like the Hippocratic Oath. (shrink)

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

Volume 20, Issue 3, March 2020, Page 77-79.

Volume 20, Issue 3, March 2020, Page 75-77.

In the last years, TV documentaries, articles in popular magazines, and Internet content have increased the public visibility of deep brain stimulation (DBS). The media may have also provoked significant clinical and public interest in potential future applications for treating psychiatric disorders beyond the current use of DBS in neurological disorders. In this article, we review and discuss the topic of patient and public understanding of DBS, focusing on both the clinical consequences of patient understanding as well as the broader (...) social consequences of public understanding. The literature and the experience of clinicians suggest that strongly optimistic media reports of DBS have had detrimental consequences for informed consent and the management of patient expectations before and after surgery. Likewise, this context has created complex issues for trust between clinicians, patients, and their families and may have hard-to-predict social impacts including on the relationships between public understanding of neuroscience, biological therapies, stigma, and mental illness. We propose an approach to tackle the clinical and social consequences of media messages on public understanding within a broad and interdisciplinary effort with concrete actions. This approach includes actions by all key players, including not only providers but also patients and their family members, as well as journalists. To further address issues at the intersection of informed consent and patient expectation, there should be more discussion on and actual testing and measurement of these recommendations or similarly minded practice changes. (shrink)

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

In this chapter, I consider the idea that physician-assisted death might come into question in the cases of psychiatric patients who are incapable of making autonomous choices about ending their lives. I maintain that the main arguments for physician-assisted death found in recent medical ethical literature support physician-assisted death in some of those cases. After assessing several possible criticisms of what I have argued, I conclude that the idea that physicianassisted death can be acceptable in some cases of psychiatric patients (...) who lack autonomy ought to be taken into account in assessing the moral and legal acceptability of physician-assisted death. (shrink)

The development of a code of ethics for a profession can be an indicator of the coherence and stability of a discipline as a unique and singular entity. Since “bioethics”, as a discipline, is not one profession but many, practiced by persons with not one but many varying responsibilities and training, it has been argued that no code of ethics is possible for the discipline(s) of bioethics. I argue that a code of ethics is possible for bioethics by looking at (...) the nature of the various disciplines and noting necessary overlap between them, and deriving the ethics from the nature of the discipline(s) themselves. I show how this can be done by arguing that strict rules about funding and conflict of interest are necessary for bioethicists. (shrink)

The conduct of nurse managers, and health service managers more widely, has been subject to scrutiny and critique because of high-profile organisational failures in healthcare. This raises concerns about the practice of nursing management and the use of codes of professional and managerial conduct. Some responses to such failures seem to assume that codes of conduct will ensure or at least increase the likelihood that ethical management will be practised. Codes of conduct are general principles and rules of normative standards, (...) including ethical standards, and guides for action of agents in particular roles. Nurse managers seem to stride two roles. Contra some accounts of the roles of a professional (nurse) and that of a manager, it is claimed that there is no intrinsic incompatibility of the roles though there is always the possibility that it could become so and likewise for codes of conduct. Codes of conduct can be used to support nurse managers in making practical decisions via an ‘outside in’ approach with an emphasis on the use of principles and an ‘inside out’ approach with an emphasis on the agent’s character. It is claimed that both approaches are necessary, especially as guides to ethical action. However, neither is sufficient for action because judgement and choice will always be required (principles always underdetermine action) as will a conducive environment that positively influences good judgement by being supportive of the basic principles and values of healthcare institutions. The response to the Covid-19 pandemic has created a unique set of circumstances in which the practical judgement, including ethical judgement, of nurse managers at all levels is being tested. However, the pandemic could be a turning point because staff and institutions (temporarily) freed from managerialism have demonstrated excellent practice supportive of ethical and other practical decision making. Organisations need to learn from this post pandemic. (shrink)

The General Medical Council renewed its guidance on consent in 2020. In this essay, I argue that the 2020 guidance does not advance on the earlier, 2008 guidance in regard to treatments that doctors are obliged to offer to patients. In both, doctors are instructed to not provide treatments that are not in the overall benefit, or clinical interests, of the patient; although, patients are absolutely entitled to decline treatment. As such, consent has two aspects, and different standards apply to (...) each aspect. To explore this paradigm, I propose the reconceptualisation of consent as a person’s freedom to achieve treatment, using Amartya Sen’s approach. Sen explains that freedom has two aspects: process and opportunity. Accordingly, a patient’s freedom to achieve treatment would comprise a process for the identification of proper treatment, followed by an opportunity for the patient to accept or decline this treatment. As per Sen, the opportunity aspect is to be assessed by the standard of public reason, whereas the standard for the process aspect is variable and contingent on the task at hand. I then use this reconceptualised view of consent to analyse case law. I show that senior judges have conceived the patient’s opportunity to be encompassed in information, which is to be decided by public reason. On the other hand, the process aspect relies on the private reason of medical professionals. Given the nature of professionalism, this reliance is inescapable, and it is maintained in the case law that is cited in both guidances. (shrink)

Debates about the ethics of health care and medical research in contemporary pluralistic democracies often arise partly from competing religious and secular values. Such disagreements raise challenges of balancing claims of religious liberty with claims to equal treatment in health care. This paper proposes several mid-level principles to help in framing sound policies for resolving such disputes. We develop and illustrate these principles, exploring their application to conscientious objection by religious providers and religious institutions, accommodation of religious priorities in biomedical (...) research, and treatment of patients’ religious views in doctor–patient encounters. Given that no sound set of guiding principles yields precise solutions for every policy dispute, we explore how morally sound democracies might deliberatively resolve such policy issues, following our proposed principles. Taken together and carefully interpreted, these principles may help in guiding difficult decision making in the indefinitely large realm where government, medical providers, and patients encounter problems concerning religion and medicine. (shrink)

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)

The purpose of this paper is to utilize virtue ethics as the appropriate paradigm by which to improve health care delivery to transgender individuals. Health disparities for transgender individuals occur external to the medical environment as well as internal to the medical profession. A commitment to virtue ethics should be undertaken to improve the care to transgender individuals. In this manuscript I call on virtue ethics to address the intersectionality of such environmental structures for the promotion of the good of (...) the patient as per the telos of medicine by Edmund Pellegrino, consistent with the eudaimonia of Aristotle’s Nicomachean Ethics. Virtue ethics is the appropriate paradigm for which bioethics can address the framework that poses barriers to access to health care and maintenance of health through a lack of competent, knowledgeable and compassionate providers for the transgender population. Further, I pose that ascribing to improving the care to the individual transgender patient involves a call to action to overcome social ecological spheres of influence that are affecting the health of the individual and thereby the population of the transgender individuals as a whole. Through virtue ethics, the virtuous physician improves the health of the transgender individual and the character of themselves and the profession of medicine. (shrink)

After considering two of Pellegrino’s papers that address the relation between philosophy of medicine and medical ethics, I identify several overarching problems in his account that revolve around his self-described essentialism and the lack of a systematic attempt to relate clinical medicine to biomedicine and public health. I address these from the critical realist position of Bernard Lonergan, who grounds both metaphysics and ethics on the normative structure of human inquiry and seeks to understand historical development, such as we are (...) witnessing in health science and health care, in terms of the dynamic structure of the human good. I conclude that Lonergan’s generalized empirical method and hierarchical account of world order provide a potentially dynamic framework on which to build a more comprehensive philosophy of medicine than one whose foundations rest primarily on a phenomenology of the clinical encounter and the telos of medicine. (shrink)

There has been significant debate about whether the moral norms of medical practice arise from some feature or set of features internal to the discipline of medicine. In this article, I analyze Edmund Pellegrino’s conception of the internal morality of medicine, and situate it in the context of Alasdair MacIntyre’s influential account of “practice.” Building upon MacIntyre, Pellegrino argued that medicine is a social practice with its own unique goals—namely, the medical, human, and spiritual good of the patient—and that the (...) moral norms that govern medical practice are derived from these goals. After providing an overview of Pellegrino’s work, I discuss some forceful objections to his theory—specifically, that it is too rigid and incapable of entering into dialogue with contemporary values systems; that it is dependent on an external conception of human flourishing; and that it is incompatible with the rapidly changing nature of modern medicine. In the final section of this article, I consider how theorists working in the Hippocratic tradition might respond to these objections against ethical essentialism by drawing upon MacIntyre’s historico-cultural method as well as what he calls Aristotle’s “metaphysical biology.”. (shrink)

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

A new kind of argument has been proposed to explain why health-care workers can sometimes refuse to offer a service or treatment. But this new kind of argument must also be evaluated and invoked differently.

Are professional roles bound by the norms of ordinary morality? This article begins with a discussion of two existing models that give contrary answers to this question; the practice model detaches professional ethics from ordinary morality, while the translation model denies any real divergence. It is argued that neither model can give a satisfying account of how professional roles ground distinct claims that are morally authoritative. The promise model is articulated and defended, wherein the obligations of professional roles are grounded (...) in an act of self-binding by the profession; the public is the promisee, and thereby entitled to make role-dependent claims. This model retains a connection to ordinary morality, but does not reduce role authority to individual conscience. Legitimate promises bind the role holder even in the face of moral disagreement. (shrink)

The fundamental claim that the practice of medicine is essentially a moral enterprise remains highly contentious, not least among the dominant traditional moral theories. The medical profession itself is today characterized by multicultural pluralism and moral relativism that have left the Hippocratic moral tradition largely in disarray. In this paper, I attempt to clarify the ambiguity about practicing medicine as a moral enterprise and echo Pellegrino’s call for a phenomenologically and teleologically derived philosophy of medicine. I proffer a realistic trifocal (...) matrix in which the virtuous moral agency and the teleologically derived moral imperative of the physician are comprehensively integrated with an action-guiding practical analytical framework for the resolution of ethical dilemmas in medicine. I argue that this trifocal perspective points us towards an authentic philosophy of medicine that is not only verifiable through Lonerganian self-appropriation, but also authentically objective through the possible moral self-transcendence of the good physician. (shrink)

Objective The President's Council on Bioethics in 2008 reaffirmed the necessity of the dead donor rule and the legitimacy of the current criteria for diagnosing both neurological and cardiac death. In spite of this report, many have continued to express concerns about the ethics of donation after circulatory death, the validity of determining death using neurological criteria and the necessity for maintaining the dead donor rule for organ donation. I analysed the dead donor rule for its effect on the virtuous (...) practice of medicine by physicians caring for potential organ donors.Results The dead donor rule consistently impedes physicians in fulfilling their primary duty to act for the good of their prospective donor patients. This compromises the virtue of fidelity. It also weakens many other virtues necessary for physicians to provide excellent end-of-life care.Conclusions The dead donor rule, while ethically powerful in theory, loses its force during translation to the bedside. This is so because the rule mandates simultaneous life and death within the same body for organ donation, a biological status that is inherently contradictory. The rule should be rejected as an ethical norm governing vital organ transplantation at the end of life. Its elimination will strengthen the doctor–patient relationship and foster trustworthiness in organ procurement. (shrink)

In response to physicians who refuse to provide medical services that are contrary to their ethical and/or religious beliefs, it is sometimes asserted that anyone who is not willing to provide legally and professionally permitted medical services should choose another profession. This article critically examines the underlying assumption that conscientious objection is incompatible with a physician’s professional obligations (the “incompatibility thesis”). Several accounts of the professional obligations of physicians are explored: general ethical theories (consequentialism, contractarianism, and rights-based theories), internal morality (...) (essentialist and non-essentialist conceptions), reciprocal justice, social contract, and promising. It is argued that none of these accounts of a physician’s professional obligations unequivocally supports the incompatibility thesis. (shrink)

Ethically challenging or controversial medical procedures have prompted increasing requests for the exercise of conscientious objection, and caused concerns about how and when it should be practised. This paper clarifies definitions, especially with regard to discrimination, and explores the restrictions, duties, and practical limitations, in order to suggest criteria for its practice. It also argues that a conscientious refusal to treat, where there is therapeutic doubt, is a valid form of conscientious objection. An email survey sent to General Practitioners (GPs), (...) explored the adherence to the suggested criteria, and assessed the outcomes, in terms of acceptability, impact, and difficulties experienced by the GPs, their colleagues and their patients. The results demonstrate high acceptability of conscientious objection, and better outcomes when the suggested criteria are adhered to. The GPs would support education to improve the practice of conscientious objection to a professional level, which could further improve outcomes and acceptability. (shrink)

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

Christopher Boorse is very skeptical of there being a pathocentric internal morality of medicine. Boorse argues that doctors have always engaged in activities other than healing, and so no internal morality of medicine can provide objections to euthanasia, contraception, sterilization, and other practices not aimed at fighting pathologies. Objections to these activities have to come from outside of medicine. I first argue that Boorse fails to appreciate that such widespread practices are compatible with medicine being essentially pathocentric. Then I contend (...) that the pathocentric essence, properly understood, does not prohibit physicians from engaging in actions that are not aimed at combating pathologies, but rather supports an internal morality of medicine that allows medical providers to refuse without penalty to engage in practices that promote pathologies. (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)

Recent controversial cases of killings by police have generated competing Black Lives Matter and Blue Lives Matter movements. Blue Lives Matter proponents claim that the focus on and protests in light of police killings of unarmed black persons is unwarranted. Part of this dispute turns on the moral evaluation of the killing of citizens by law enforcement. To address the dispute, I develop an account of the special moral obligations of law enforcement and show how it can be applied. I (...) argue that members of law enforcement have special moral obligations against killing citizens. The account generates moral guidance for law enforcement in a number of other ways. It implies, finally, that the Blue Lives Matter proponents fundamentally misunderstand the ethics of law enforcement. (shrink)

This paper seeks to define and delimit the scope of the social responsibilities of health professionals in reference to the concept of a social contract. While drawing on both historical data and current empirical information, this paper will primarily proceed analytically and examine the theoretical feasibility of deriving social responsibilities from the phenomenon of professionalism via the concept of a social contract.

Increasingly, physicians are being asked to provide technical services that many believe are morally wrong or inconsistent with their beliefs about the meaning and purposes of medicine. This controversy has sparked persistent debate over whether practitioners should be permitted to decline participation in a variety of legal practices, most notably physician-assisted suicide and abortion. These debates have become heavily politicized, and some of the key words and phrases are being used without a clear understanding of their meaning. In this essay, (...) I endeavor, firstly, to clarify the meaning of some of these terms: conscience, conscientious action, professional judgment, conscientious objection, conscience clauses, civil disobedience, and tolerance. I argue that use of the term conscientious objection to describe these refusals by health care professionals is mistaken and confusing. Secondly, relying on a proper understanding of the moral and technical character of medical judgment, the optimal deference that the state and markets ought to have toward professions, and general principles of Lockean tolerance for a diversity of practices and persons in a flourishing, pluralistic, democratic society, I offer a defense of tolerance with respect to the deeply held convictions of physicians and other health care professionals who hold minority views on contested but legal medical practices. (shrink)

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

This past July, five professional societies, whose members together provide the majority of clinical care in the United States, published a statement objecting to “inappropriate legislative interference” with the physician‐patient relationship and reiterated the importance of “putting patients’ best interests first.” Such a collective response is helpful, but given the apparently growing interest among legislators in legislating aspects of physician‐patient communications, individual physicians, too, may have to face this problem. What should a physician do when confronted with a law that (...) attempts to intervene in the doctor‐patient relationship in a way that the physician believes undercuts good medical care? (shrink)

Medical clinicians – doctors, nurses, nurse practitioners etc. – are charged to act for the good of their patients. But not all ways of acting for a patient's good are on par: some are paternalistic; others are not. What does it mean to act paternalistically, both in general and specifically in a medical context? And when, if ever, is it permissible for a clinician to act paternalistically? -/- This paper deals with the first question, with a special focus on paternalism (...) in medicine. While it is easy to give a rough characterization of paternalism (i.e. acting for another's good against that person's will), it is surprisingly difficult to provide a unified account of the myriad of actions that seem to count as paternalistic. After surveying four accounts of paternalism, I argue that two – what I call the authority and beneficence accounts – are the strongest on offer. According to the authority account, a clinician acts paternalistically when, for her patient's good, she usurps his decision-making authority. According to the beneficence account, a clinician acts paternalistically when, for her patient's good, she acts only or overrindingly out of concern for his good. I show how the difference between these accounts matters (in part) for how we should think about the nature of surrogate decision making in medicine. I argue that there are reasons – albeit hardly decisive – to prefer the beneficence account to the authority account. I conclude by considering whether attempts by clinicians to rationally persuade their patients to pursue a particular course of action should be thought of as paternalistic. (shrink)

Medical clinicians – doctors, nurses, nurse practitioners etc. – are charged to act for the good of their patients. But not all ways of acting for a patient's good are on par: some are paternalistic; others are not. What does it mean to act paternalistically, both in general and specifically in a medical context? And when, if ever, is it permissible for a clinician to act paternalistically? In Medical Paternalism Part 1, I answered the first question. This paper answers the (...) second. The place of paternalism in clinical medicine is best understood, I argue, in terms of the potential for conflict between the autonomy principle and the beneficence principle. The first enjoins clinicians to respect the decisions of patients with respect to their (the patients') own care. The second enjoins clinicians to act for the good of their patients. Clinicians act paternalistically, I argue, when they act on the beneficence principle to the exclusion of the autonomy principle. Understanding just what these principles amount to (particularly the autonomy principle) reveals that the autonomy principle defeasibly trumps the beneficence principle and that, as a result, acting paternalistically (at least when it comes to competent patients) is presumptively impermissible. (shrink)

During the past decade, screening tests using computed tomography have disseminated into practice and been marketed to patients despite neither conclusive evidence nor professional agreement about their efficacy and cost-effectiveness at the population level. This phenomenon raises questions about physicians' professional roles and responsibilities within the setting of medical innovation, as well as the appropriate scope of patient autonomy and access to unproven screening technology. This article explores how physicians ought to respond when new screening examinations that lack conclusive evidence (...) of overall population benefit emerge in the marketplace and are requested by individual patients. To this end, the article considers the nature of evidence and how it influences decision-making for screening at both the public policy and individual patient levels. We distinguish medical and ethical differences between screening recommended for a population and screening considered on an individual patient basis. Finally, we discuss specific cases to explore how evidence, patient risk factors and preferences, and physician judgment ought to balance when making individual patient screening decisions. (shrink)

Extracorporeal membrane oxygenation (ECMO) is typically viewed as a time-limited intervention—a bridge to recovery or transplant—not a destination therapy. However, some patients with decision-making capacity request continued ECMO support despite a poor prognosis for recovery and lack of viability as a transplant candidate. In response, critical care teams have asked for guidance regarding the ethical permissibility of unilateral withdrawal over the objections of a capacitated patient. In this article, we evaluate several ethical arguments that have been made in favor of (...) withdrawal, including distributive justice, quality of life, patients’ rights, professional integrity, and the Equivalence Thesis. We find that existing justifications for unilateral withdrawal of ECMO support in capacitated patients are problematic, which leads us to conclude that either: (1) additional ethical arguments are necessary to defend this approach or (2) the claim that it is not appropriate to use ECMO as a destination therapy should be questioned. (shrink)

Elucidating a metaphysics of medicine is vital for framing a coherent medical ethics. In this paper, I examine the historical case of Avicenna, the eleventh century physician-philosopher. Avicenna radicalizes the dissective power of reason using a logicized Aristotelian metaphysics to clarify concepts at the metaphysical level, which I call his anatomy of being. One of the practical consequences of Avicenna’s metaphysics is a dehumanizing eschatology of death. I outline the main elements of Avicenna’s thought that constitute his anatomy of being. (...) Through an examination of his logic, metaphysics, and psychology, I show how Avicenna develops a dissective logic. I conclude that one’s epistemology, as a method of knowing, entails a metaphysics, and, in turn, results in an ethical stance to the object of knowledge. For Avicenna, mental dissective logic applied to humans results in dehumanization, thereby destroying the humanistic impulse of medicine. (shrink)