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)

Healthcare professionals often need to make clinical decisions that carry profound ethical implications. As such, they require a tool that will make decision-making intuitive. While the discussion about the principles that should guide clinical ethics has been going on for over two thousand years, it does not seem that making such decisions is becoming any more straight forward. With an abundance of competing ethical systems and frameworks for their application in real life, the clinician is still often not sure how (...) to proceed in the face of ethical dilemmas, either due to a lack of background ethical knowledge or experience in applying it. This paper will discuss whether considering what one would expect one’s friend to do if one was the patient, or what would one think they would do for a friend if they were the patient, can be a helpful, more intuitive, tool for clinical decision-making that can produce outcomes that are congruent with major ethical systems. (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)

BackgroundMedical ethics has recently seen a drive away from multiple prescriptive approaches, where physicians are inundated with guidelines and principles, towards alternative, less deontological perspectives. This represents a clear call for theory building that does not produce more guidelines. Phronesis (practical wisdom) offers an alternative approach for ethical decision-making based on an application of accumulated wisdom gained through previous practice dilemmas and decisions experienced by practitioners. Phronesis, as an ‘executive virtue’, offers a way to navigate the practice virtues for any (...) given case to reach a final decision on the way forward. However, very limited empirical data exist to support the theory of phronesis-based medical decision-making, and what does exist tends to focus on individual practitioners rather than practice-based communities of physicians.MethodsThe primary research question was: What does it mean to medical practitioners to make ethically wise decisions for patients and their communities? A three-year ethnographic study explored the practical wisdom of doctors (n = 131) and used their narratives to develop theoretical understanding of the concepts of ethical decision-making. Data collection included narrative interviews and observations with hospital doctors and General Practitioners at all stages in career progression. The analysis draws on neo-Aristotelian, MacIntyrean concepts of practice- based virtue ethics and was supported by an arts-based film production process.ResultsWe found that individually doctors conveyed many different practice virtues and those were consolidated into fifteen virtue continua that convey the participants’ ‘collective practical wisdom’, including the phronesis virtue. This study advances the existing theory and practice on phronesis as a decision-making approach due to the availability of these continua.ConclusionGiven the arguments that doctors feel professionally and personally vulnerable in the context of ethical decision-making, the continua in the form of a video series and app based moral debating resource can support before, during and after decision-making reflection. The potential implications are that these theoretical findings can be used by educators and practitioners as a non-prescriptive alternative to improve ethical decision-making, thereby addressing the call in the literature, and benefit patients and their communities, as well. (shrink)

Background: Strong relations between medicine and public health have long been advocated. Today, professional medical practice assumes joint clinical/public health objectives:GPs are expected to practice community medicine;Hospital specialists can be involved in disease control and health service organisation;Doctors can teach, coach, evaluate, and coordinate care;Clinicians should interpret protocols with reference to clinical epidemiology. Public health physicians should tailor preventive medicine to individual health risks. This paper is targeted at those practitioners and academics responsible for their teams’ professionalism and the accessibility (...) of care, where the authors argue in favour of the epistemological integration of clinical medicine and public health. Main text: Based on empirical evidence the authors revisit the epistemological border of clinical and public health knowledge to support joint practice. From action-research and cognitive psychology, we derive clinical/public health knowledge categories that require different transmission and discovery techniques. The knowledge needed to support the universal human right to access professional care bridges both clinical and public health concepts, and summons professional ethics to validate medical decisions. To provide a rational framework for teaching and research, we propose the following categories:‘Know-how/practice techniques’, corresponding a.o. to behavioural, communication, and manual skills;‘Procedural knowledge’ to choose and apply procedures that meet explicit quality criteria;‘Practical knowledge’ to design new procedures and inform the design of established procedures in new contexts; andTheoretical knowledge teaches the reasoning and theory of knowledge and the laws of existence and functioning of reality to validate clinical and public health procedures. Even though medical interventions benefit from science, they are, in essence, professional: science cannot standardise eco-biopsychosocial decisions; doctor-patient negotiations; emotional intelligence; manual and behavioural skills; and resolution of ethical conflicts. Conclusion: Because the quality of care utilises the professionals’ skill-base but is also affected by their intangible motivations, health systems should individually tailor continuing medical education and treat collective knowledge management as a priority. Teamwork and coaching by those with more experience provide such opportunities. In the future, physicians and health professionals could jointly develop clinical/public health integrated knowledge. To this end, governments should make provision to finance non-clinical activities. (shrink)

Following the Introduction, the second section of this essay lays out Tom Cavanaugh’s helpful and convincing account of the enduring significance of the Hippocratic Oath in terms of how it responds to the problem of iatrogenic harm. The third section discusses something underemphasized in Cavanaugh’s account, namely, the key role of the virtue of piety within the Oath and the profession it establishes, and argues that this virtue should be regarded as integral to an authentic Hippocratic ethic. The fourth and (...) final section briefly examines the connection between medicine and philosophy, focusing on how both should be seen as wisdom-seeking ways of life, and shows the relevance of this for regarding the virtue of piety as the key virtue of medical practice. (shrink)

Physicians try hard to alleviate mental and physical ailments of their patients. Thus, they are heavily burdened by observing ethics and staying well-informed while improving health of their patients. A major ethical concern or dilemma in medication is that some physicians know their behavior is unethical, yet act against their moral compass. This study develops models of theory–practice gap, offering optimal solutions for the gap. These solutions would enhance self-motivation or remove external obstacles to stimulate ethical practices in medicine. The (...) Constructivist Grounded Theory Methodology is applied here where the participants and the main researcher mutually interacted with each other. Data collection was performed through qualitative methods including observation and semi-structured interviews with 21 physicians and medical students. Initial and focused coding was done, from which principal concepts were later extracted. MAXQDA software was used for analyzing data. Analysis of twelve major concepts in the study resulted in two factors and solution groups, from which four general notions influencing the ethical theory and practice gap in medicine were extracted: (1) providing effective education to change attitude and behavior; (2) considering motivational and emotional factors; (3) reconstructing regulations and processes to facilitate ethical practice; (4) conducting comprehensive and systematic studies. The existing medical educational system needs to be reconsidered to add to individual internal motivation, including optimizing persuasion strategies, maximizing participation of students, adhering to virtuous ethical theories, and fostering emotions. Additionally, regulations and processes can be reconstructed to remove practical obstacles and promote ethical practice with insignificant damages to individual self-motivation. (shrink)

Physicians frequently ask whether they should give patients what they want, usually when there are considerations pointing against doing so, such as medicine’s values and physicians’ obligations. It has been argued that the source of medicine’s values and physicians’ obligations lies in what has been dubbed “the internal morality of medicine”: medicine is a practice with an end and norms that are definitive of this practice and that determine what physicians ought to do qua physicians. In this paper, I defend (...) the claim that medicine requires a morality that is internal to its practice, while rejecting the prevalent characterization of this morality and offering an alternative one. My approach to the internal morality of medicine is constructivist in nature: the norms of medicine are constructed by medical professionals, other professionals, and patients, given medicine’s end of “benefitting patients in need of prima facie medical treatment and care.” I make the case that patients should be involved in the construction of medicine’s morality not only because they have knowledge that is relevant to the internal morality of medicine—namely, their own values and preferences—but also because medicine is an inherently relational enterprise: in medicine the relationship between physician and patient is a constitutive component of the craft itself. The framework I propose provides an authoritative morality for medicine, while allowing for the incorporation, into that very morality, of qualified deference to patient values. (shrink)

Health care systems can positively influence our personal decision-making and health-related behavior only if we trust them. I propose a conceptual analysis of the trust relation between the public and a healthcare system, drawing from healthcare studies and philosophical proposals. In my account, the trust relation is based on an epistemic component, epistemic authority, and on a value component, the benevolence of the healthcare system. I argue that it is also modified by the vulnerability of the public on healthcare matters, (...) and by the system’s credibility. I apply my proposed analysis of public trust in health care systems to the phenomenon of vaccine hesitancy, a tendency to question vaccine policies, and to seek alternative vaccine schedules or to refuse vaccination. Understanding the role of trust and its components can be key to understanding the phenomenon. (shrink)

Modern health data practices come with many practical uncertainties. In this paper, I argue that data subjects’ trust in the institutions and organizations that control their data, and their ability to know their own moral obligations in relation to their data, are undermined by significant uncertainties regarding the what, how, and who of mass data collection and analysis. I conclude by considering how proposals for managing situations of high uncertainty might be applied to this problem. These emphasize increasing organizational flexibility, (...) knowledge, and capacity, and reducing hazard. (shrink)

Acting for the good of the patient is the most fundamental and universally acknowledged principle of medical ethics. However, given the complexity of modern medicine as well as the moral fragmentation of contemporary society, determining the good is far from simple. In his philosophy of medicine, Edmund Pellegrino develops a conception of the good that is derived from the internal morality of medicine via the physician-patient relationship. It is through this healing relationship that rights, duties, and privileges are defined for (...) both physicians and patients. Moreover, this relationship determines the characteristics or virtues that are necessary to engage in the medical telos. This paper addresses the role of the moral virtues in clinical medicine and the physician-patient relationship. First, it provides a brief background of the Aristotelian foundations of virtue-ethics. Second, it delves into Pellegrino’s philosophy of medicine understood as a practice oriented towards a teleological goal. Third, it relates the telos of medicine to the notion of the medical community as a fundamentally moral community. Finally, it concludes with a section that creates a dialogue between virtue ethics and principlism. (shrink)

The internet of things is increasingly spreading into the domain of medical and social care. Internet-enabled devices for monitoring and managing the health and well-being of users outside of traditional medical institutions have rapidly become common tools to support healthcare. Health-related internet of things (H-IoT) technologies increasingly play a key role in health management, for purposes including disease prevention, real-time tele-monitoring of patient’s functions, testing of treatments, fitness and well-being monitoring, medication dispensation, and health research data collection. H-IoT promises many (...) benefits for health and healthcare. However, it also raises a host of ethical problems stemming from the inherent risks of Internet enabled devices, the sensitivity of health-related data, and their impact on the delivery of healthcare. This paper maps the main ethical problems that have been identified by the relevant literature and identifies key themes in the on-going debate on ethical problems concerning H-IoT. (shrink)

Can doctors maintain good character? This paper shifts the focus from patient care to ethical considerations that bear on the physician and impact her as a person. By decentering patient care, the paper highlights certain factors that habituate a particular way of reasoning that is not conducive to inculcating good character. Such factors include, standards of professionalism, being influenced by external monitors, and emphasis on adherence to guidelines. While such factors may benefit patients, they often adversely affect the character of (...) physicians. (shrink)

Social, political, and economic environments play an active role in nurturing professional virtue. Yet, these environments can also lead to the erosion of virtue. As such, professional virtue is fragile and vulnerable to environmental shifts. While physicians are often considered to be among the most virtuous of professional groups, concern has also always existed about the impact of commercial arrangements on physicians’ willingness and capacity to enact their professional virtues. This article examines the ways in which commercial arrangements have been (...) negotiated to secure medical virtue from real or perceived threats of erosion. In particular, we focus on the concern surrounding conflicts of interest arising from commercial arrangements that have developed as a result of neoliberal economic and social policies. The deregulation of medical markets and privatization of services have produced new commercial relationships that are often misunderstood by patients, publics, and physicians themselves. ‘Conflicts of interest’ policies have been introduced in an attempt to safeguard ethical conduct and medical practice. However, a number of virtue ethicists have critiqued these policies as inadequate for securing virtue. We examine the ways in which commercial arrangements have been seen to impact upon medical virtue, both historically and in the context of modern medicine. We then describe and critique current efforts to restore clinical virtue through both conflict of interest policies and through virtue ethics. Finally, we suggest some possible ways of addressing the corrosive effects of neoliberalism on medical virtue. (shrink)

In this article we revisit the concept of a profession. Definitions of the concept are readily encountered in the literature on professions and we have collected a sample of such definitions. From this sample we distil frequently occurring elements and ask whether a synthesis of these elements adequately explains the concept. We find that bringing the most frequently occurring elements together does not adequately address the reason that society differentiates professions from other occupations or activities -- why there is a (...) concept of ‘profession’ at all. We suggest an alternative approach that attempts to make sense of the concept at a more general level. This more philosophical approach employs analytical tools from Julius Kovesi, Patricia Hanna and Bernard Harrison to address the question of what is the point of the concept. (shrink)

The capacity to collect and analyse data is growing exponentially. Referred to as ‘Big Data’, this scientific, social and technological trend has helped create destabilising amounts of information, which can challenge accepted social and ethical norms. Big Data remains a fuzzy idea, emerging across social, scientific, and business contexts sometimes seemingly related only by the gigantic size of the datasets being considered. As is often the case with the cutting edge of scientific and technological progress, understanding of the ethical implications (...) of Big Data lags behind. In order to bridge such a gap, this article systematically and comprehensively analyses academic literature concerning the ethical implications of Big Data, providing a watershed for future ethical investigations and regulations. Particular attention is paid to biomedical Big Data due to the inherent sensitivity of medical information. By means of a meta-analysis of the literature, a thematic narrative is provided to guide ethicists, data scientists, regulators and other stakeholders through what is already known or hypothesised about the ethical risks of this emerging and innovative phenomenon. Five key areas of concern are identified: informed consent, privacy, ownership, epistemology and objectivity, and ‘Big Data Divides’ created between those who have or lack the necessary resources to analyse increasingly large datasets. Critical gaps in the treatment of these themes are identified with suggestions for future research. Six additional areas of concern are then suggested which, although related have not yet attracted extensive debate in the existing literature. It is argued that they will require much closer scrutiny in the immediate future: the dangers of ignoring group-level ethical harms; the importance of epistemology in assessing the ethics of Big Data; the changing nature of fiduciary relationships that become increasingly data saturated; the need to distinguish between ‘academic’ and ‘commercial’ Big Data practices in terms of potential harm to data subjects; future problems with ownership of intellectual property generated from analysis of aggregated datasets; and the difficulty of providing meaningful access rights to individual data subjects that lack necessary resources. Considered together, these eleven themes provide a thorough critical framework to guide ethical assessment and governance of emerging Big Data practices. (shrink)

The idea of philosophy as a kind of therapy, though by no means standard, has been present in metaphilosophical reflection since antiquity. Diverse versions of it were also discussed and applied by more recent authors such as Wittgenstein, Hadot and Foucault. In order to develop an explicit, general and systematic model of therapeutic philosophy a relatively broad and well-structured account provided by Martha Nussbaum is subjected to analysis. The results obtained, subsequently, form a basis for a new model constructed around (...) the set of notions intrinsically connected with any, philosophical, psychological, or medical, form of therapy. The conceptual framework of: disease and its symptoms, the health ideal, the process of treatment with its techniques, therapeutic theory, physician, patient, and the physician-patient relationship is constructed and investigated in the context of its possible metaphilosophical use. An illustrative application of this scheme to philosophical therapy developed by Stoicism is, then, discussed. Finally, the issue of the therapeutic metaphilosophy's scope as well as the problem of therapeutic philosophy's specificity and integrity are briefly indicated. (shrink)

According to some proponents of an empirical medical ethics, medical ethics should take the experience, insights, and arguments of doctors and other medical practitioners as their point of departure. Medical practitioners are supposed to have ‘moral wisdom.’ In this view, the moral beliefs of medical practitioners have a special status. In sections I-IV, I discuss two possible defences of such a status. The first defence is based on the special status of the moral beliefs of the health professional as an (...) expert in medical ethics, and the second defence on the special status of the health professional’s moral beliefs as a practitioner. The first defence is built up around the opposition between experts and laypersons, while the second defence rests on the opposition between practitioners and theorists. In sections V and VI, I examine the interrelations between empirical ethics and anti-theory in ethics. Some regard empirical ethics as a laudable alternative to theory-driven normative ethics. I explore their objections against ethical theory and ethical theorising, and conclude that they are not valid. In the last section, VII, I discuss the role of ethicists in medical practice. (shrink)

Background: Discussions about medical errors facilitate professional learning for physicians and may provide emotional support after an error, but little is known about physicians’ attitudes and practices regarding error discussions with colleagues.Methods: Survey of faculty and resident physicians in generalist specialties in Midwest, Mid-Atlantic and Northeast regions of the US to investigate attitudes and practices regarding error discussions, likelihood of discussing hypothetical errors, experience role-modelling error discussions and demographic variables.Results: Responses were received from 338 participants . In all, 73% of (...) respondents indicated they usually discuss their mistakes with colleagues, 70% believed discussing mistakes strengthens professional relationships and 89% knew at least one colleague who would be a supportive listener. Motivations for error discussions included wanting to learn whether a colleague would have made the same decision , wanting colleagues to learn from the mistake and wanting to receive support . Given hypothetical scenarios, most respondents indicated they would likely discuss an error resulting in no harm , minor harm or major harm . Fifty-seven percent of physicians had tried to serve as a role model by discussing an error and role-modelling was more likely among those who had previously observed an error discussion .Conclusions: Most generalist physicians in teaching hospitals report that they usually discuss their errors with colleagues, and more than half have tried to role-model discussions. However, a significant number of these physicians report that they do not usually discuss their errors and some do not know colleagues who would be supportive listeners. (shrink)

Illness creates a range of negative emotions in patients including anxiety, fear, powerlessness, and vulnerability. There is much debate on the ‘therapeutic’ or ‘helping’ nurse–patient relationship. However, despite the current agenda regarding patient-centred care, the literature concerning the development of good interpersonal responses and the view that a satisfactory nursing ethics should focus on persons and character traits rather than actions, nursing ethics is dominated by the traditional obligation, act-centred theories such as consequentialism and deontology. I critically examine these theories (...) and the role of duty-based notions in both general ethics and nursing practice. Because of well-established flaws, I conclude that obligation-based moral theories are incomplete and inadequate for nursing practice. I examine the work of Hursthouse on virtue ethics’ action guidance and the v-rules. I argue that the moral virtues and a strong (action-guiding) version of virtue ethics provide a plausible and viable alternative for nursing practice. I develop an account of a virtue-based helping relationship and a virtue-based approach to nursing. The latter is characterized by three features: (1) exercising the moral virtues such as compassion; (2) using judgement; and (3) using moral wisdom, understood to include at least moral perception, moral sensitivity, and moral imagination. Merits and problems of the virtue-based approach are examined. I relate the work of MacIntyre to nursing and I conceive nursing as a practice: nurses who exercise the virtues and seek the internal goods help to sustain the practice of nursing and thus prevent the marginalization of the virtues. The strong practice-based version of virtue ethics proposed is context-dependent, particularist, and relational. Several areas for future philosophical inquiry and empirical nursing research are suggested to develop this account yet further. (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)

A summary of the philosophical literature on trust.

A meta-ethical analysis demonstrates that care ethics is a grounded in a distinct mode of moral reasoning. This is comprised primarily of the rejection of principles such as impartiality, and the endorsement of emotional or moral virtues such as compassion, as well as the notion that the preservation of relations may override the interests of the individuals involved in them. The main conclusion of such a meta-ethical analysis is that such meta-ethical foundations of care ethics are not sound. Reasonable alternatives (...) for care ethics may be its formulation as an additional principle within an established principlist framework, or the move to a dialogical ethics, where the good to be acted upon is not decided in advance but rather critically discussed and established within the encounter of the parties involved. (shrink)

Clinical psychologists' and nonpsychiatric physicians' attitudes and behaviors in sexual and confidentiality boundary violations were examined. The 171 participants' responses were analyzed by profession, sex, and status (student, resident, professional) on semantic differential, boundary violation vignettes, and a version of Pope, Tabachnick, and Keith-Spiegel's (1987) ethical scale. Psychologists rated sexual boundary violation as more unethical than did physicians (p<.001). Rationale (p<.01) and timing (p<.001) influenced ratings. Psychologists reported fewer sexualized behaviors than physicians (p<05). Professional experience (p<.01) and sex (p<.05) were (...) associated with confidence-violating behavior. Overall, 78% of the sample reported attitudes or behaviors associated with boundary violations. The behavior violations were correlated (r=.49). Actual violators rated vignette violators more leniently than did nonviolators (p<.01). (shrink)

The Hippocratic Oath, the Hippocratic tradition, and Hippocratic ethics are widely invoked in the popular medical culture as conveying a direction to medical practice and the medical profession. This study critically addresses these invocations of Hippocratic guideposts, noting that reliance on the Hippocratic ethos and the Oath requires establishingwhat the Oath meant to its author, its original community of reception, and generally for ancient medicine what relationships contemporary invocations of the Oath and the tradition have to the original meaning of (...) the Oath and its original reception what continuity exists and under what circumstances over the last two-and-a-half millenniums of medical-moral reflections what continuity there is in the meaning of professionalism from the time of Hippocrates to the 21st century, and what social factors in particular have transformed the medical profession in particular countries. This article argues that the resources for a better understanding of medical professionalism lie not in the Hippocratic Oath, tradition, or ethos in and of themselves. Rather, it must be found in a philosophy of medicine that explores the values internal to medicine, thus providing a medical-moral philosophy so as to be able to resist the deformation of medical professionalism by bioethics, biopolitics, and governmental regulation. The Oath, as well as Stephen H. Miles' recent monograph, The Hippocratic Oath and the Ethics of Medicine, are employed as heuristics, so as to throw into better light the extent to which the Hippocratic Oath, tradition, and ethics can provide guidance and direction, as well as to show the necessity of taking seriously the need for a substantive philosophy of medicine. (shrink)

We are currently in the midst of a revival of interest in thevirtues. A number of contemporary moral philosophers havedefended a virtue-based approach to ethics. But does thisrenewal of interest in the virtues have much to contributeto medical ethics and medical practice? This paper criticallydiscusses this question. It considers and rejects a number ofimportant arguments that purport to establish the significanceof the virtues for medical practice. Against these arguments,the paper seeks to show that while the virtues have a genuinerole to (...) play in medical ethics, it is a limited role, one thatis subordinate to the role that other moral concepts such asrules and principles play. (shrink)

The evidence-based medicine movement advocates basing all medical decisions on certain types of quantitative research data and has stimulated protracted controversy and debate since its inception. Evidence-based medicine presupposes an inaccurate and deficient view of medical knowledge. Michael Polanyi’s theory of tacit knowledge both explains this deficiency and suggests remedies for it. Polanyi shows how all explicit human knowledge depends on a wealth of tacit knowledge which accrues from experience and is essential for problem solving. Edmund Pellegrino’s classic treatment of (...) clinical judgment is examined, and a Polanyian critique of this position demonstrates that tacit knowledge is necessary for understanding how clinical judgment and medical decisions involve persons. An adequate medical epistemology requires much more qualitative research relevant to the clinical encounter and medical decision making than is currently being done. This research is necessary for preventing an uncritical application of evidence-based medicine by health care managers that erodes good clinical practice. Polanyi’s epistemology shows the need for this work and provides the structural core for building an adequate and robust medical epistemology that moves beyond evidence-based medicine. (shrink)

In this paper, I take a critical stance on the emerging field of nanoethics. After an introductory section, “Conceptual Foundations of Nanotechnology” considers the conceptual foundations of nanotechnology, arguing that nanoethics can only be as coherent as nanotechnology itself and then discussing concerns with this latter concept; the conceptual foundations of nanoethics are then explicitly addressed in “Conceptual Foundations of Nanoethics”. “Issues in Nanoethics” considers ethical issues that will be raised through nanotechnology and, in “What’s New?”, it is argued that (...) none of these issues is unique to nanotechnology. In “It’s a Revolution!”, I express skepticism about arguments which hold that, while the issues themselves might not be unique, they nevertheless are instantiated to such a degree that extant moral frameworks will be ill-equipped to handle them. In “What’s Different?”, I draw plausible distinctions between nanoethics and other applied ethics, arguing that these latter might well identify unique moral issues and, as such, distinguish themselves from nanoethics. Finally, in “What Now?”, I explore the conclusions of this result, ultimately arguing that, while nanoethics may fail to identify novel ethical concerns, it is at least the case that nanotechnology is deserving of ethical attention, if not a new associative applied ethic. (shrink)

Physicians try hard to alleviate mental and physical ailments of their patients. Thus, they are heavily burdened by observing ethics and staying well-informed while improving health of their patients. A major ethical concern or dilemma in medication is that some physicians know their behavior is unethical, yet act against their moral compass. This study develops models of theory–practice gap, offering optimal solutions for the gap. These solutions would enhance self-motivation or remove external obstacles to stimulate ethical practices in medicine. The (...) Constructivist Grounded Theory Methodology is applied here where the participants and the main researcher mutually interacted with each other. Data collection was performed through qualitative methods including observation and semi-structured interviews with 21 physicians and medical students. Initial and focused coding was done, from which principal concepts were later extracted. MAXQDA software was used for analyzing data. Analysis of twelve major concepts in the study resulted in two factors and solution groups, from which four general notions influencing the ethical theory and practice gap in medicine were extracted: (1) providing effective education to change attitude and behavior; (2) considering motivational and emotional factors; (3) reconstructing regulations and processes to facilitate ethical practice; (4) conducting comprehensive and systematic studies. The existing medical educational system needs to be reconsidered to add to individual internal motivation, including optimizing persuasion strategies, maximizing participation of students, adhering to virtuous ethical theories, and fostering emotions. Additionally, regulations and processes can be reconstructed to remove practical obstacles and promote ethical practice with insignificant damages to individual self-motivation. (shrink)

Ethical decision making in medicine has recently seen calls to move towards less prescriptive- based approaches that consider the particularities of each case. The main alternative call from the literature is for better understanding of phronesis concepts applied to decision making. A well-cited phronesis-based approach is Kaldjian’s five-stage theoretical framework: goals, concrete circumstances, virtues, deliberation and motivation to act. We build on Kaldjian’s theory after using his framework to analyse data collected from a three-year empirical study of phronesis and the (...) medical community. The data are a set of narratives collected in response to asking a medical community what making ethically wise decisions means to them. We found that Kaldjian’s five concepts are present in the accounts to some extent but that one of the elements, motivation, is constructed as playing a different, though still crucial role. Rather than being an end-stage of the process as Kaldjian’s framework suggests, motivation was constructed as initiating the process and maintaining the momentum of taking a phronesis-based approach. The implications for medical ethics decision-making education are significant as motivation itself is a highly complex concept. We therefore theorise that motivation is required for leading in, continuing and completing the actions of the ethical decision taken. Appreciating the central importance of motivation through the whole of Kaldjian’s framework has implications for cultivating the virtues of phronesis and courage to take the right course of action. (shrink)

As face shields are dusted off and conferences go virtual again, Omicron reminds us how the once-novel coronavirus ruptured our collective idea of medical training. For nearly 2 years, social media...

Shared Decision-Making is a widely accepted model of the physician–patient relationship providing an ethical environment in which physician beneficence and patient autonomy are respected. It acknowledges the moral responsibility of physician and patient by promoting a deliberative collaboration in which their individual expertise—complementary in nature, equal in importance—is emphasized, and personal values and preferences respected. Its goal coincides with Pellegrino and Thomasma’s proximate end of medicine, that is, a technically correct and morally good healing decision for and with a particular (...) patient. We argue that by perfecting the intellectual ability to apprehend the complexity of clinical situations, and through a perfection of the application of the first principles of practical reason, prudence is able to point toward the right and good shared medical decision. A prudent shared medical decision is therefore always in keeping with the kind of person the physician and the patient have chosen to be. (shrink)

For several years, the Democratic Republic of Congo has been the scene of strikes by the country’s doctors. The strikers’ demands are essentially financial and statutory and are intended to put pressure on the government. In this country, as is the case almost everywhere in the world, medical strikes are allowed. Every worker has the right to denounce by strike working conditions that are considered unacceptable. But are doctors just like any other workers? Do they not have particular moral obligations (...) linked to the specificities of their profession? To shed light on these questions, the authors of this article propose three essential moral benchmarks that can be generalized to medical strike situations elsewhere in the world. The first concerns the recognition of the right to strike for doctors, including for strictly financial reasons. Health professionals cannot be asked to work in inhuman working conditions or without a salary to support their families. The second benchmark argues that it is unacceptable for this right to strike to be exercised if it sacrifices the most vulnerable patients and thus denies the very essence of the medical profession. A third benchmark complicates the reflection by reminding us that the extreme dilapidation of the Congolese health system makes it impossible to organise a minimum quality service in the event of a strike. To overcome these difficulties, we propose a national therapeutic alliance between doctors and citizens to put patients back at the centre of the health system’s concerns. (shrink)

In this paper, I supplement T. A. Cavanaugh’s arguments against physician-assisted suicide in his book, Hippocrates’ Oath and Asclepius’ Snake, by focusing more specifically on the dangers of the misuse of physician power and on the virtues essential to restrain such power. Since Cavanaugh’s starting point is similar to Edmund Pellegrino’s views on the fundamental ends of medicine, I start with the question of the proper ends of medicine. Cavanaugh’s interpretation of the Hippocratic Oath as the limitation of physician power (...) to heal and to kill raises the issue of the proper use of physician power over the patient. In order to support and strengthen Cavanaugh’s case, I use Richard Zaner’s discussion of physician power over the patient and the attendant duty to use such power in a responsible way. Finally, I supplement Cavanaugh’s discussion with a fuller account of physician virtues as they relate to physician-assisted suicide. I first discuss the ends of medicine, medical power, and physician-assisted suicide. Second, I discuss the relationship between virtue and physician-assisted suicide. Third, I draw some final conclusions. (shrink)

Principlism, the bioethical theory championed by Tom Beauchamp and James Childress, is centered on the four moral principles of beneficence, non-maleficence, respect for autonomy, and justice. Two key processes related to these principles are specification—adding specific content to general principles—and balancing—determining the relative weight of conflicting principles. I argue that both of these processes necessarily involve an appeal to human goods and evils, and therefore require a theory of the good. A significant problem with principlism is that it lacks a (...) theory of the good and consequently does not have an adequate solution to the problems of specification and balancing. My conclusion is that principlism must adopt some account of human well-being in order to be a satisfactory bioethical framework. (shrink)

In this analysis of the ethical dimensions of doctors’ participation in macroallocation we set out to understand the skills they use, how they are acquired, and how they influence performance of the role. Using the principles of grounded moral analysis, we conducted a semi-structured interview study with Australian doctors engaged in macroallocation. We found that they performed expertise as argument, bringing together phronetic and rhetorical skills founded on communication, strategic thinking, finance, and health data. They had made significant, purposeful efforts (...) to gain skills for the role. Our findings challenge common assumptions about doctors’ preferences in argumentation, and reveal an unexpected commitment to practical reason. Using the ethics of Paul Ricoeur in our analysis enabled us to identify the moral meaning of doctors’ skills and learning. We concluded that Ricoeur’s ethics offers an empirically grounded matrix for ethical analysis of the doctor’s role in macroallocation that may help to establish norms for procedure. (shrink)

By way of a case story, two common presuppositions in the academic debate on conscientious objection in healthcare are challenged. First, the debate typically presupposes a sharp division between conscience-based refusals based on personal core moral beliefs and refusals based on professional reasons. Only the former might involve the moral gravity to warrant accommodation. The case story challenges this division, and it is argued that just as much might sometimes be at stake morally in refusals based on professional reasons. The (...) objector's moral integrity might be equally threatened in objections based on professional reasons as in objections based on personal beliefs. Second, the literature on conscientious objection typically presupposes that conflicts of conscience pertain to well-circumscribed and typical situations which can be identified as controversial without attention to individualising features of the concrete situation. However, the case shows that conflicts of conscience can sometimes be more particular, born from concrete features of the actual situation, and difficult, if not impossible, to predict before they arise. Guidelines should be updated to address such ‘situation-based’ conscientious refusals explicitly. (shrink)

The purpose of this study is to determine empirically the state of the art of the medical care, when healthcare personal is confronted with ethical dilemmas related with the care they give to the geriatric population. An observational, longitudinal, prospective and qualitative study was conducted by analyzing the correlation between healthcare personnel–patient relationship, and ethical judgments regarding dilemmas that arise in daily clinical practice with geriatric patients. Mexican healthcare personnel with current active practices were asked to write up an ethical (...) dilemma that arose frequently or that had impacted their medical practice. From the narrative input, we were able to draw up a database with 421 dilemmas, and those corresponding to patients 60 years and older were selected (n = 54, 12.8 %). The axiological analysis of the narrative dilemmas of geriatric patients was made using dialectical empiricism. The axiological analysis values found most frequently were classified into three groups: the impact of healthcare, the roles of the physician, and refusal of therapy; the healthcare role of educator, caring for the patients’ life and the risk of imminent death where the values found more often. The persistence and universality of certain dilemmas in geriatrics calls for awareness and requires a good training in the ethical discernment of these dilemmas. This would help to improve substantially the care and the life quality of this population. (shrink)

In this paper I argue that medical education must remain attuned to the interests that physicians have in their own self-development despite ongoing calls for ethics education aimed at ensuring physicians maintain focus on the interests of the patient and society. In particular, I argue that medical education should advance criteria defining what counts as an educationally worthwhile activity from the perspective of the medical student understood as a learner. I offer a preliminary account and justification of such criteria, arguing (...) that such criteria warrant a process of ethical formation that better serves the interests of medical students, their patients and society. (shrink)

Phronesis has become a buzzword in contemporary medical ethics. Yet, the use of this single term conceals a number of significant conceptual controversies based on divergent philosophical assumptions. This paper explores three of them: on phronesis as universalist or relativist, generalist or particularist, and natural/painless or painful/ambivalent. It also reveals tensions between Alasdair MacIntyre’s take on phronesis, typically drawn upon in professional ethics discourses, and Aristotle’s original concept. The paper offers these four binaries as a possible analytical framework for classifying (...) and evaluating accounts of phronesis in the medical ethics literature. It argues that to make sense of phronesis as a putative ideal in professional medical ethics—for example, with the further aim of crafting interventions to cultivate phronesis in medical ethics education—the preliminary question of which conception of phronesis is most serviceable for the aim in question needs to be answered. The paper identifies considerable lack of clarity in the current discursive field on phronesis and suggests how that shortcoming can be ameliorated. (shrink)

BackgroundMany medical emergency practices are regulated by written procedures that normally provide reliable guidelines for action. In some cases, however, the consequences of following rule-based instructions can have unintended negative consequences. The article discusses a case - described on a type level - where the consequences of following a rule formulation could have been fatal.Case presentationA weak and elderly patient has cardiac arrest, and a Do Not Resuscitate clause is written in the patient’s medical record. Paramedics at the scene cannot (...) see that the patient’s general appearance match conditions which would indicate the DNR clause, so they start cardiopulmonary resuscitation, and the patient survives. This turns out to be a crucial decision. The DNR clause is from an earlier bout with serious disease from which the patient has recovered, against all odds, and someone has forgotten to remove the clause from the medical record.AnalysisIn order to be able to interpret the validity of written guidelines, paramedics and other health workers need to develop personal skills that transcend the ability simply to follow written instructions. Within traditional virtue ethics, personal judgment is conceived of as crucial for being able to make ‘good’ autonomous decisions. Virtue ethical analyses, decision-making abilities and non-technical communication skills are important as conceptual tools when health workers need to make difficult clinical decisions.ConclusionThe case study accentuates the significance of prudent judgment in medical practice. In the case described, the consequence of trusting the written advance directive could have been fatal, but the point is general: for the purpose of achieving excellent organizational performance, it is insufficient for health workers to rely uncritically on rules and procedures. Even the clearest rule formulations must be interpreted contextually in order to determine ethically correct behavior and avoid potential negative consequences that are not in the patient’s best interests. (shrink)

This article questions the commonly held view that professional ethics is grounded in general ethical principles, in particular, respect for client (or patient) autonomy and beneficence in the treatment of clients (or patients). Although these are admirable as general ethical principles, we argue that there is considerable logical difficulty in applying them to the professional-client relationship. The transition from general principles to professional ethics cannot be made because the intended conclusion applies differently to each of the parties involved, whereas the (...) premise is a general principle that applies equally to both parties. It is widely accepted that professionals are required to recognize that clients or patients possess rights to autonomy that are more than the general rights to personal autonomy accepted in ordinary social life, and that professionals are expected to display beneficence toward their clients that is more than the beneficence expected of anyone in ordinary social life. The comparative component of professional ethics is an intrinsic feature of the professional situation, and thus it cannot be bypassed in working out a proper professional ethics. Thus, we contend, the proper professional treatment of clients or patients has not been explained by appeal to general ethical principles. (shrink)

This study is a contribution to the bioethical debate about new and possibly emerging reproductive technologies. Its point of departure is the intuition, which many people seem to share, that using such technologies to select non-disease traits – like sex and emotional stability - in yet unborn children is morally problematic, at least more so than using the technologies to avoid giving birth to children with severe genetic diseases, or attempting to shape the non-disease traits of already existing children by (...) environmental means, like education. The study employs philosophical analysis for the purpose of making this intuition intelligible and judging whether it is justified. Different ways in which the moral problems posed by reproductive technologies are often framed in bioethical debates are criticised as inadequate for this task. In particular, it is argued that the intuition cannot fully be made sense of in terms of harm to the children that such technologies help create. The study attempts to elaborate an alternative to that broadly consequentialist approach, by drawing on Martin Heidegger’s philosophy of technology, Hans Jonas’s ethics, and Aristotle’s practical philosophy, as it has been received and developed in the hermeneutical tradition. It is suggested that reproductive choices, unlike decisions for already born children, are characterised by a peculiar one-sidedness: the future child appears to the parents as something wholly theirs to decide about, not as a concrete other with whom they must interact in a responsive and attuned way. This is problematic because it means that such choices cannot call upon the particularised moral understanding only gained in interpersonal encounters. In particular, it makes them easily shaped by various tendencies, to which parents are always susceptible, to relate to children in instrumentalising ways, and at risk of reinforcing such tendencies. However, this does not mean that all uses of reproductive technologies are equally troubling. When selecting against severe disease the parents can rely on a widely shared illness experience to escape the dangers that one-sidedness involves. It is concluded that the intuition under discussion, thus explicated and in some ways qualified, makes sense morally. (shrink)