BackgroundPsychiatric staff members have the power to decide the options that frame encounters with patients. Intentional as well as unintentional framing can have a crucial impact on patients’ opportunities to be heard and participate in the process. We identified three dominant ethical perspectives in the normative medical ethics literature concerning how doctors and other staff members should frame interactions in relation to patients; paternalism, autonomy and reciprocity. The aim of this study was to describe and analyse statements describing real work (...) situations and ethical reflections made by staff members in relation to three central perspectives in medical ethics; paternalism, autonomy and reciprocity.MethodsAll staff members involved with patients in seven adult psychiatric and six child and adolescent psychiatric clinics were given the opportunity to freely describe ethical considerations in their work by keeping an ethical diary over the course of one week and 173 persons handed in their diaries. Qualitative theory-guided content analysis was used to provide a description of staff encounters with patients and in what way these encounters were consistent with, or contrary to, the three perspectives.ResultsThe majority of the statements could be attributed to the perspective of paternalism and several to autonomy. Only a few statements could be attributed to reciprocity, most of which concerned staff members acting contrary to the perspective. The result is presented as three perspectives containing eight values.•Paternalism; 1) promoting and restoring the health of the patient, 2) providing good care and 3) assuming responsibility.•Autonomy; 1) respecting the patient’s right to self-determination and information, 2) respecting the patient’s integrity and 3) protecting human rights.•Reciprocity; 1) involving patients in the planning and implementation of their care and 2) building trust between staff and patients.ConclusionsPaternalism clearly appeared to be the dominant perspective among the participants, but there was also awareness of patients’ right to autonomy. Despite a normative trend towards reciprocity in psychiatry throughout the Western world, identifying it proved difficult in this study. This should be borne in mind by clinics when considering the need for ethical education, training and supervision. (shrink)

This article explores solidarity as an ethical concept underpinning rules in the global health context. First, it considers the theoretical conceptualisation of the value and some specific duties it supports (ie: its expression in the broadest sense and its derivative action-guiding duties). Second, it considers the manifestation of solidarity in two international regulatory instruments. It concludes that, although solidarity is represented in these instruments, it is often incidental. This fact, their emphasis on other values and their internal weaknesses diminishes the (...) action-guiding impact of the solidarity rules. The global health and human subject research scene needs a completely new instrument specifically directed at means by which solidarity can be achieved, and a reformed infrastructure dedicated to realising that value. (shrink)

Emergency hormonal contraception (EHC) has been available from pharmacies in the UK without prescription for 11 years. In the Republic of Ireland this service was made available in 2011. In both jurisdictions the respective regulators have included ‘conscience clauses’, which allow pharmacists to opt out of providing EHC on religious or moral grounds providing certain criteria are met. In effect, conscientious objectors must refer patients to other providers who are willing to supply these medicines. Inclusion of such clauses leads to (...) a cycle of cognitive dissonance on behalf of both parties. Objectors convince themselves of the existence of a moral difference between supply of EHC and referral to another supplier, while the regulators must feign satisfaction that a form of regulation lacking universality will not lead to adverse consequences in the long term. We contend that whichever of these two parties truly believes in that which they purport to must act to end this unsatisfactory status quo. Either the regulators must compel all pharmacists to dispense emergency contraception to all suitable patients who request it, or a pharmacist must refuse either to supply EHC or to refer the patient to an alternative supplier and challenge any subsequent sanctions imposed by their regulator. (shrink)

Although the teaching of medical ethics and law in medical education is an old story that has been told many times in medical literature, recent studies show that medical students and physicians lack confidence when faced with ethical dilemmas and medico-legal issues. The adverse events rates and medical lawsuits are on the rise whereas many medical errors are mostly due to negligence or malpractices which are preventable. While it is true that many medical schools teach their students medical law and (...) ethics, there are wide variations in what is being taught because there is no universally agreed syllabus. Yet the knowledge of medical law and ethics is closely relevant to the medical profession and that failure in abiding the law may result in serious civil or even criminal consequences. While this paper does not propose to lay detailed analysis of the relevant areas of law or ethics, it proposes to cover some legal areas so as to highlight and bring to attention the need for a medical law and ethics course. This article also considers the problems faced and recommendation as to future directions to be taken with respect to teaching medical law and ethics. It concludes with a suggested course outline for the teaching of medical law and ethics. (shrink)

This articles assesses the arguments that bioethicists have presented for the view that patient’ autonomy has value over and beyond its instrumental value in promoting the patients’ wellbeing. It argues that this view should be rejected and concludes that patients’ autonomy should be taken to have only instrumental value in medicine.

The concept of responsibility for health is a significant feature of health discourse and public health policy, but application of the concept is poorly understood. This paper offers an analysis of the concept in two ways. Following an examination of the use of the word ‘responsibility’ in the nursing and wider health literature using three examples, the concept of ‘responsibility for health’ as fulfilling a social function is discussed with reference to policy documents from the UK. The philosophical literature on (...) moral responsibility is introduced, and in considering two versions, reactive attitudes and accountability, it is argued that in application both can be regarded, though with different emphasis, as being constituted in three parts: a responsible agent; having obligations ; and being susceptible to being held responsible if he fails to meet them. The three‐stage model is consistent with the examples of the word responsibility in use, but application to the social function model causes a number of problems for healthcare practice, especially for the reactive attitudes account. Apart from considerable problems in stating what exactly the obligations are and how they can be justified; and how blame might justly be apportioned and by whom, the very ideas of obligation and blame are in conflict within healthcare systems and professional nursing practice which have foundations deeply embedded in the notion of the supremacy of personal autonomy. It is concluded that current application of the concept of responsibility for health is conceptually incoherent, and if it is to retain its place in health policy and discourse, urgent remedy is required. (shrink)

Abortion is the central issue in the conscientious objection debate. In this article I demonstrate why this is so for two philosophical viewpoints prominent in American culture. One, represented by Patrick Lee and Robert P. George, holds that the fundamental moral value of being human can be found in bare life and the other, represented by Tom Beauchamp and James Childress, holds that this fundamental value is found in the life that can choose and determine itself. First, I articulate Lee (...) and George’s philosophical theory and demonstrate how the fundamental moral value of their theory, personhood, is represented in the issue of abortion. Second, I examine Beauchamp and Childress’ theoretical vision and demonstrate how their fundamental moral value, the right to autonomous self-determination, is represented in abortion. Third, I sketch the theoretical and practical dynamics of the conscientious objection debate as well as each author’s understanding of conscience. Fourth, I demonstrate how abortion, which represents their respective fundamental value, shapes each perspectives’ approach to the conscientious objection debate. I conclude that because each theory finds its fundamental value represented in the issue of abortion, each perspective is bound to engage the conscientious objection debate in a way that centers on the issue of abortion. (shrink)

Respect for autonomy is an important moral principle within medical ethics. However, the question of whether the normative importance of respect for autonomy is derived from other moral principles (such as welfare) or has independent moral value is debatable. In this paper it is argued that the normative importance of autonomy is derived from both welfare and non-welfare considerations. Welfare considerations provide two types of reason to respect autonomy, one related to the role of autonomy in creating welfare and one (...) related to its role in constituting welfare. In addition, autonomy seems to have normative importance that is unrelated to welfare considerations. This type of normative role is difficult to defend within medical ethics, because most non-welfare justifications of autonomy work for only a proportion of the autonomous decisions that patients make and give no clear guidance on how to respond to autonomous yet welfare-reducing treatment requests. A recent account of autonomy (Stephen Darwall’s “demand” account) provides a nuanced defence of autonomy that does not rely on welfare considerations. Darwall’s approach seems to work well within medical ethics and provides a principled explanation of how to respond to autonomous patient requests for treatment options that may not be in their best medical interests. It is argued that to fully respect autonomy within a medical consultation, practitioners must consider non-welfare autonomy as well as instrumental and intrinsic welfare-related autonomy. (shrink)

ABSTRACTGiven its intimate relationship with the human body and its environment, biotechnology innovation, and more particularly stem cell research innovations as a part thereof, implicate diverse social and moral/ethical issues. This paper explores some of the most important and controversial moral concerns raised by human embryonic stem cell research , focusing on concerns relating to the wellbeing of the embryo and the wellbeing of society . It then considers how and whether these concerns are dealt with in regulatory instruments in (...) Argentina, a southern developing country, examining in particular whether the values underlying these concerns have been translated into practical and effective rules reflective of the primary moral positions advanced. It concludes that Argentina's current state of stem cell research governance fails to consistently reflect the moral positions that have formed and is inadequate given Argentina's activity in this field. (shrink)

End-of-life decision making frequently involves a complex balancing of clinical, cultural, social, ethical, religious and economic considerations. Achieving a happy balance of these sometimes-competing interests, however, can be particularly fraught in a family-centric society like Singapore where the family unit often retains significant involvement in care determinations necessitating careful consideration of the family’s position during the decision-making process. While various decision-making tools such as relational autonomy, best interests principle and welfare-based models have been proposed to help navigate such difficult decision-making (...) processes, their application in practical terms, however, is dubious at best. This case report is presented to highlight these issues and explore the utility of these frameworks within the Singapore end-of-life care context when the interests of the family may be dissonant from those of the patient. (shrink)

Patient-centered pharmacy practice involves increased pharmacist engagement in patient care. This increased involvement can sometimes require diverse decision-making when handling various situations, ranging from simple matters to major ethical dilemmas. There is literature about pharmacy ethics in developed Western countries. However, little is known about pharmacists’ practices in many developing countries. For example, there is a paucity of research conducted in the area of pharmacy ethics in Jordan. This study aimed to explore the manner in which ethical dilemmas were handled (...) by Jordanian pharmacists, the resources used and their attitudes towards them. Semi-structured, face to face interviews were carried out with 30 Jordanian registered pharmacists. The transcribed interviews were thematically analysed for emerging themes. Four major themes were identified: legal practice; familiarity with the code of ethics; personal judgement, cultural and religious values; and Experience. Findings showed that ethical decision-making in pharmacy practice in Jordan was decisively influenced by pharmacists’ personal moral values, legal requirements and managed by exercising common sense and experience. This pointed to gaps in Jordanian pharmacists’ understanding and application of basic principles of pharmacy ethics and highlighted the need for professional ethics training, incorporating pharmacy ethics courses in pharmacy undergraduate curricula, as well as professional development courses. This study highlighted that paternalism, personal values and legal obligations were major drivers influencing decision-making processes of Jordanian pharmacists. Findings also highlighted an inclination towards lack of respect for patient autonomy. This illuminated the need for increasing pharmacists’ literacy in professional ethics. (shrink)

In accordance with a recent statement released by the World Health Organization, the Canadian province of Ontario is moving to ban payment for plasma donation. This is partially based on contentions that remuneration for blood and blood products undermines autonomy and personal dignity. This paper is dedicated to evaluating this claim. I suggest that traditional autonomy-based arguments against commodification of human body parts and substances are less compelling in the context of plasma donation in Canada, but that there is another (...) autonomy-based objection to paid plasma donation that has not received sufficient attention. Namely, the stigma that surrounds exchanging plasma for payment makes it difficult to make an autonomous decision to engage in this activity. I suggest that this problem can be overcome in one of two ways; by banning payment for plasma, or by reducing the stigma surrounding this practice. I provide an indication of how we might work to achieve the latter, contending that this possibility should be taken seriously, due to the difficulties in achieving a sufficient supply of plasma without remuneration. (shrink)

In a Swedish setting physicians are unlikely to give explicitly paternalistic reasons when asked about their attitudes towards patients’ involvement in decision-making. There is considerable risk that they will disguise their paternalism by giving ‘socially correct answers’. We suggest that disguised paternalism can be revealed with the help of indexes based on certain responses in postal questionnaires. The indexes were developed using material from a study examining attitudes of Swedish physicians to physician-assisted suicide (PAS). Apart from being asked about their (...) attitudes, they were asked to prioritise between different arguments for and against PAS. One argument for PAS was: “PAS should be permitted out of respect for patients’ autonomy”. One argument against PAS was: “PAS should not be permitted since the non-maleficence principle in this case takes precedence over respecting patients’ autonomy”. Responses to the latter argument formed the cornerstone of a disguised-paternalism index, while an autonomy index was based on answers to the former argument. Applying our indexes to data from the PAS survey, we found that female GPs, surgeons, and older male physicians were least paternalistic. Among female physicians one finds both the most autonomy-respecting groups (female surgeons and GPs) and the least autonomy-respecting groups (female oncologists and psychiatrists); together with older male physicians in general, female GPs are the group displaying least disguised paternalism. We suggest that questionnaires exploring paternalism might be improved by including case-specific questions or statements by which to explore disguised paternalism. Here our indexes might be useful tools. (shrink)

Communicable diseases, especially those that are highly contagious, are on the rise and each of us, no matter who we are or where we live, is equally at risk of transmitting contagious diseases to others as we are of contracting such diseases from others. Because contagious diseases are as readily passed state-to-state as person-to-person, we all have a stake in every country's ability to enact effective infectious disease control policies, while policies grounded in shared values are more likely to gain (...) widespread acceptance and thereby prove most effective. This paper suggests that principlism proved invaluable as an ethical framework for resolving hard medical cases and setting health care policy because it nicely “fits” dilemmas that arise in the context of the special relationship between doctors and patients or within family units. It then argues that communitarianism provides the better foundation for crafting infectious diseases control policies because contagious diseases, which often pass between perfect strangers, raise questions about the moral obligations we owe to (or are entitled to demand of) people with whom we share no “special” relationship. Accordingly, a socially embedded framework such as communitarianism may be a better fit for the more socially embedded ethical dilemmas of communicable diseases. (shrink)

The purpose of this article is to re-examine an ethic of care as the main ethical approach to nursing practice in light of past and present developments in nursing ethics, and to briefly speculate whether or not it will survive within nursing in the future. Overall, it is maintained throughout that the terms ?caring?, ?nursing? and an ?ethic of care? are inextricably linked. This is because, it is argued, professionally focused nursing practices are based predominantly on a well-recognised moral commitment (...) to deliver expert care, and that a care-based ethic is the major factor in the construction and maintenance of these practices. Subsequently, the influences and developments of a caring ethic in nursing are firstly re-examined, and the discussion is supported by evidence from more recent nursing research and theoretical developments. Consideration is given to the philosophical underpinnings of both care theory and caring ethics, and the fundamental importance of caring in nursing, as an interpersonal relationship and as an appropriate ethical response, is made transparent. Finally, an outline of the future possibilities that may affect an ethic of care in nursing is offered. (shrink)

I will argue that there are difficulties with the application of the four principles approach to incompetent children. The most important principle – respect for autonomy – is not directly applicable to incompetent children and the most appropriate modification of the principle for them is not clear. The principle of beneficence – that one should act in the child’s interests – is complicated by difficulties in assessing what a child’s interests are and to which standard of interests those choosing for (...) children should be held. A further problem with the four principles approach is that parental authority does not follow clearly from the four principles. (shrink)

This article critically examines the development and consensus outputs of the Concussion in Sport Group. We examine the six Consensus Statements between 2001 and 2023 to explore the challenges that the presence of contextual forces pose to the development of effective and ethically justifiable medical guidelines to manage situations involving brain-injured athletes. First, we discuss the implicit and explicit ethical framework and goals underlining the statements. Secondly, drawing on a relational account of athlete choice, we expound on the limitations of (...) the framework, concentrating on those resulting from a simplified understanding of athlete autonomy. Thirdly, we conclude by proposing a series of recommendations to improve concussion management protocols: (1) adopting a broader understanding of autonomy built upon relational accounts, beyond just the healthcare professional-athlete relationship; (2) further minimizing conflicts of interest that increase athletes’ vulnerability and hinder decision-making ability; (3) enhancing healthcare professional training to allow better adjustment of treatment plans to athletes’ contexts; and (4) promoting research on sociocultural elements affecting athletes’ vulnerability and autonomy. (shrink)

There is an ongoing debate about whether multifetal pregnancy reduction from twins to singletons (2-to-1 MFPR) is morally permissible. By applying the all or nothing problem to the cases of reducing twin pregnancies to singletons, Räsänen argues that an implausible conclusion seems to follow from two plausible claims: (1) it is permissible to have an abortion and (2) it is wrong to abort only one fetus in a twin pregnancy. The implausible conclusion is that women considering 2-to-1 MFPR for social (...) reasons ought to abort both fetuses rather than just one. To avoid the conclusion, Räsänen suggests that it is best to carry both fetuses to term and give one for adoption. In this article, I argue that Räsänen’s argument fails for two reasons: the inference from (1) and (2) to the conclusion rests on a bridge principle that does not work in certain circumstances, and there is good reason to reject the claim that it is wrong to abort only one fetus. (shrink)

Mental health legislation that requires patients to accept ‘care’ has come under increasing scrutiny, prompted primarily by a human rights ethic. Epistemic issues in mental health have received some attention, however, less attention has been paid to the possible epistemic problems of mental health legislation existing. In this manuscript, we examine the epistemic problems that arise from the presence of such legislation, both for patients without a prior experience of being detained under such legislation and for those with this experience. (...) We also examine how the doctor is legally obligated to compound the epistemic problems by the knowledge they prioritise and the failure to generate new knowledge. Specifically, we describe the problems of testimonial epistemic injustice, epistemic silencing, and epistemic smothering, and address the possible justification provided by epistemic paternalism. We suggest that there is no reasonable epistemic justification for mental health legislation that creates an environment that fundamentally unbalances the doctor–patient relationship. Significant positive reasons to counterbalance this are needed to justify the continuation of such legislation. (shrink)

In “Nudging, Bullshitting, and the Meta-Nudge”, the author responds to William Simkulet’s claim that nudging is bullshitting (according to Harry Frankfurt’s analysis of bullshit and bullshitting), and therefore nudging during the process of informed consent renders consent invalid. The author argues that nudging is not necessarily bullshitting and then explains that although this issue is philosophically interesting, practically speaking, even if nudging is bullshitting, it does not follow that nudging necessarily renders informed consent invalid. This is obviously true in those (...) situations in which nudging during the process of informed consent is unavoidable. The author concludes with a discussion of the meta-nudge and suggests that physicians can use the meta-nudge to eliminate or decrease the power of inappropriate, problematic, or undesirable nudges. (shrink)

BackgroundFamily presence during adult cardiopulmonary resuscitation is still not widely implemented. Based on empirical evidence, various national and international professional organizations recommend allowing relatives to be present during resuscitation. However, healthcare providers worldwide are still reluctant to make it standard care.PurposeThis paper is a part of an ongoing cross-cultural study that aims to solicit attitudes of healthcare providers working in emergency departments towards family presence during cardiopulmonary resuscitation. This paper reports the qualitative data from surveying healthcare providers working in an (...) emergency department at a university-affiliated hospital in Singapore.MethodHealthcare workers were asked to fill out an online survey, including both quantitative and qualitative questions. Their attitudes were critically analyzed and compared with existing empirical data.ResultsMajority of healthcare workers believed that relatives should not be present during c... (shrink)

Organ trafficking is officially banned in several countries and by the main Nephrology Societies. However, this practice is widespread and is allowed or tolerated in many countries, hence, in the absence of a universal law, the caregiver may be asked for advice, placing him/her in a difficult balance between legal aspects, moral principles and ethical judgments.In spite of the Istanbul declaration, which is a widely shared position statement against organ trafficking, the controversy on mercenary organ donation is still open and (...) some experts argue against taking a negative stance. In the absence of clear evidence showing the clinical disadvantages of mercenary transplantation compared to chronic dialysis, self-determination of the patient may conflict with other ethical principles, first of all non-maleficence. The present paper was drawn up with the participation of the students, as part of the ethics course at our medical school. It discusses the situation in which the physician acts as a counselor for the patient in the way of a sort of “reverse” informed consent, in which the patient asks advice regarding a complex personal decision, and includes a peculiar application of the four principles to the donor and recipient parties. (shrink)

In recognition of the important ethical issues posed by qualitative research in health care, the authors present key questions to aid ethical review. The purpose is to assist lay and professional members of research ethics committees in their assessment of applications involving qualitative research methods and to inform researchers intending to submit such applications for ethical approval. For the benefit of those less familiar with this type of research, the authors include an overview of different types of qualitative research, together (...) with an explanation of terms commonly used by qualitative researchers. (shrink)

Where a decision has been made to stop futile treatment of critically ill patients on an intensive care unit – what is termed withdrawal of treatment in the UK – yet no doctor is available to perform the actions of withdrawal, nurses may be called upon to perform key tasks. In this paper I present two moral justifications for this activity by offering answers to two major questions. One is to ask if it can be in patients' best interests for (...) nurses to be the key actors in withdrawal of life‐sustaining treatment. The other is to ask if there is any reason that the nursing profession should not undertake such tasks if this is so. Both these questions require the resolution of weighty moral and philosophical issues. Thus, while offering a serious attempt to provide moral justifications for nurses undertaking withdrawal, this paper also invites debate over both the aim of task division between nurses and doctors, and how we might decide what is in the best interests of patients. (shrink)

Cardiology is characterized by its state-of-the-art biomedical technology and the predominance of Evidence-Based Medicine. This predominance makes it difficult for healthcare professionals to deal with the ethical dilemmas that emerge in this subspecialty. This paper is a first endeavor to empirically investigate the axiological foundations of the healthcare professionals in a cardiology hospital. Our pilot study selected, as the target population, cardiology personnel not only because of their difficult ethical deliberations but also because of the stringent conditions in which they (...) have to make them. Therefore, there is an urgent need to reconsider clinical ethics and Value-Based Medicine. This study proposes a qualitative analysis of the values and the virtues of healthcare professionals in a cardiology hospital in order to establish how the former impact upon the medical and ethical decisions made by the latter. (shrink)

The Pharmaceutical Benefits Scheme, operating in Australia under the National Health Act 1953, provides citizens equal access to subsidised pharmaceuticals. With ever-increasing costs of medicines and global financial pressure on all commodities, the sustainability of the PBS is of crucial importance on many social and political fronts. Direct-to-consumer advertising (DTCA) of prescription medicines is fast expanding, as pharmaceutical companies recognise and reinforce marketing potentials not only in healthcare professionals but also in consumers. DTCA is currently prohibited in Australia, but pharmaceutical (...) companies continuously lobby for the ban to be lifted. There is evidence that such marketing strategies influence consumer behaviour and concerns have been raised about whether DTCA could affect government expenditure on the PBS in Australia. This pharmacy-based study explored Australian consumer attitudes towards DTCA and whether consumer attitudes regarding DTCA differ based on socioeconomic status, measured in terms of income and education. Consumers from different socioeconomic areas in Sydney were asked to respond to a survey about an advertisement created specifically for the promotion of a mock prescription medicine. Their views about the intent, value and reliability of the advertisement were explored. The study found that consumers of lower socioeconomic status were more likely to perceive DTCA as a source of valuable and reliable medical information, and that they were more likely to request an advertised medication from their physician. If DTCA of prescription medicines was to be introduced in Australia, an increase in government expenditure on the PBS would be anticipated. Findings of this study also expose a deficit in respect for patients’ right to autonomy and informed consent which should be based on evidence-based, unbiased, information rather than advertisements. (shrink)

The “therapeutic misconception” describes a process whereby research volunteers misinterpret the intentions of researchers and the nature of clinical research. This misinterpretation leads research volunteers to falsely attribute a therapeutic potential to clinical research, and compromises informed decision making, therefore compromising the ethical integrity of a clinical experiment. We review recent evidence from the neurobiology of social cognition to provide a novel framework for thinking about the therapeutic misconception. We argue that the neurobiology of social cognition should be considered in (...) any ethical analysis of how people make decisions about participating in clinical trials. The neurobiology of social cognition also suggests how the complicated dynamics of the doctor-patient relationship may unavoidably interfere with the process of obtaining informed consent. Following this argument we suggest new ways to prevent or at least mitigate the therapeutic misconception. (shrink)

Despite having worked in higher education for over twenty years, I am still, first and foremost, a practicing nurse. My employer requires me to be a nurse and my regulator regards what I do as nursing. My practice is regulated by the Code and informed by nursing ethics. If I am nurse, practicing nursing, does that mean that my students are my patients? This paper considers how the relationship that I have with my students can be informed by the ethics (...) of the nurse/patient relationship. After some initial theoretical preparation concerning argument from analogy, the paper identifies some areas for comparison between the two relationships. Areas of similarity and difference identify two areas of concern: Nurse education and educators regularly engage in coercion and surveillance in an attempt to increase student success, both of which would be considered outside nursing ethics. It is concluded that these coercive practices are not conducive to an environment where character is cultivated. Despite current financial and workforce pressures, nurse lecturers and more especially their managers would do well to return to the professional ethics of nursing to question and guide their practice. (shrink)

While copious quantities of ink have been spilled on the topic of autonomy in the context of health care, little has been written about autonomy in relation to intellectual disability. After presenting the received account of capacity, we argue that it cannot account for the moral permissibility of limiting an individual with intellectual disability’s access to diet soda. In cases of preventative medicine and intellectual disability, the philosophical motivation for the received account of capacity is incompatible with the actions it (...) recommends. We consider and reject several potential solutions; then, drawing on applied behavior analysis and the phenomenon of automatic reinforcement, we propose our own solution. The article concludes by considering the broader implications of our discussion. (shrink)

Background Paternalism/overprotection limits communication between healthcare professionals and patients and does not promote shared therapeutic decision-making. In the global north, communication patterns have been regulated to promote autonomy, whereas in the global south, they reflect the physician’s personal choices. The goal of this study was to contribute to knowledge on the communication patterns used in clinical practice in Mexico and to identify the determinants that favour a doctor–patient relationship characterized by low paternalism/autonomy. Methods A self-report study on communication patterns in (...) a sample of 761 mental healthcare professionals in Central and Western Mexico was conducted. Multiple ordinal logistic regression models were used to analyse paternalism and associated factors. Results A high prevalence of paternalism was observed among mental health professionals in Mexico. The main determinants of low paternalism/autonomy were medical specialty and gender, with female physicians being more likely to explicitly share diagnoses and therapeutic strategies with patients and their families. A pattern of highly explicit communication was strongly associated with low paternalism/autonomy. Finally, a modifying effect of age strata on the association between communication pattern or specialty and low paternalism/autonomy was observed. Conclusions Among mental health professionals in Mexico, high paternalism prevailed. Gender, specialty, and a pattern of open communication were closely associated with low paternalism/autonomy. Strengthening health professionals’ competencies and promoting explicit communication could contribute to the transition towards more autonomist communication in clinical practice in Mexico. The ethical implications will need to be resolved in the near future. (shrink)

Ethics settings allow for morally significant decisions made by humans to be programmed into autonomous machines, such as autonomous vehicles or autonomous weapons. Customizable ethics settings are a type of ethics setting in which the users of autonomous machines make such decisions. Here two arguments are provided in defence of customizable ethics settings. Firstly, by approaching ethics settings in the context of failure management, it is argued that customizable ethics settings are instrumentally and inherently valuable for building resilience into the (...) larger socio-technical systems in which autonomous machines operate. Secondly, after defining the preliminary condition of responsibility attribution and demonstrating how ethics settings enable humans to exert control over the outcomes of morally significant incidents, it is shown that ethics settings narrow the responsibility gap. (shrink)

In recent years, there has been a considerable increase in the degree of philosophical attention devoted to the question of the morality of offering financial compensation in an attempt to increase the medical supply of human body parts and products, such as plasma. This paper will argue not only that donor compensation is ethically acceptable, but that plasma donors should not be prohibited from being offered compensation if they are to give their informed consent to donate. Regulatory regimes that prohibit (...) donor compensation thus unethically prevent the typical donor from being able to give her informed consent to donate. (shrink)

Beneficence and respect for autonomy are two of the most fundamental moral duties in general and in bioethics in particular. Beyond the usual questions of how to resolve conflicts between these duties in particular cases, there are more general questions about the possible forms of the interactions between them. Only recognition of the full spectrum of possible interactions will ensure optimal moral deliberation when duties potentially conflict. This paper has two simultaneous objectives. The first is to suggest a typological scheme (...) of all possible modes of interaction; these will be classified under the “discrete,” “semi-discrete,” and “non-discrete” categories, according to whether the meaning and/or forms of expression of each duty are treated as independent from or rather as constrained by the other. The second objective is to show that all logical possibilities of interaction indeed have real expressions in medical ethics, to provide clear illustrations of each, and in particular to stress those that have usually escaped recognition. (shrink)

This paper presents a pedagogical framework for teaching cross-cultural clinical ethics. The approach, offered at the intersection of anthropology and bioethics, is innovative in that it takes on the “social sciences versus bioethics” debate that has been ongoing in North America for three decades. The argument is made that this debate is flawed on both sides and, moreover, that the application of cross-cultural thinking to clinical ethics requires using the tools of the social sciences within a principles-based framework for clinical (...) ethics. This paper introduces the curriculum and provides guidelines for how to teach cross-cultural clinical ethics. The learning points that are introduced emphasize culture in its relation to power and underscore the importance of viewing both biomedicine and bioethics as culturally constructed. (shrink)

Traditionally, physicians and parents made decisions about children’s health care based on western practices. More recently, with legal and ethical development of informed consent and recognition for decision making, children are becoming active participants in their care. The extent to which this is happening is however blurred by lack of clarity about what children — of diverse levels of cognitive development — are capable of understanding. Moreover, when there are multiple surrogate decision makers, parental and professional conflict can arise concerning (...) children’s ‘best interest’. Giving children a voice and offering choice promotes their dignity and quality of life. Nevertheless, it also presents with many challenges. Case studies using pseudonyms and changed situational identities are used in this article to illuminate the complexity of ethical challenges facing nurses in end-of-life care with children and families. (shrink)

In this essay I argue that the same considerations that justify the strong commitment to anti-paternalism that has been affirmed in bioethics over the past half century, also calls for anti-paternalistic public health policies. First, I frame the puzzle—why are citizens morally entitled to make unhealthy and medically inadvisable decisions as patients but not as consumers? I then briefly sketch the reasons why bioethicists typically reject paternalism. Next, I argue that those same reasons tell against paternalism in public health ethics (...) as well. Patients do not waive their rights to make medically inadvisable decisions when they leave their physician’s care. James Wilson disagrees. After I sketch Wilson’s arguments for paternalism in public health policy, I then argue, contra Wilson, that public health paternalism is wrong for the same reason that medical paternalism is wrong, and that the prevalence of paternalism in public policy does not mean that paternalism is morally permissible. I discuss the state’s authority to enforce paternalistic policies and I sketch an anti-paternalist vision for health policymakers. To close, I consider several objections. (shrink)

A moral problem arises when a patient refuses a treatment that would save her life. Should the patient be treated against her will? According to an influential approach to questions of biomedical ethics, certain considerations pertaining to individual autonomy provide a solution to this problem. According to this approach, we should respect the patient’s autonomy and, since she has made an autonomous decision against accepting the treatment, she should not be treated. This article argues against the view that our answer (...) to the question of whether or not the refusing patient ought to be treated should be based on these kinds of considerations pertaining to individual autonomy and maintains that finding a plausible answer to this question presupposes that we resolve questions concerning subjectivity and objectivity of individual wellbeing. (shrink)

The principle of informed consent obligates physicians to explain possible side effects when prescribing medications. This disclosure may itself induce adverse effects through expectancy mechanisms known as nocebo effects, contradicting the principle of nonmaleficence. Rigorous research suggests that providing patients with a detailed enumeration of every possible adverse event—especially subjective self-appraised symptoms—can actually increase side effects. Describing one version of what might happen (clinical “facts”) may actually create outcomes that are different from what would have happened without this information (another (...) version of “facts”). This essay argues that the perceived tension between balancing informed consent with nonmaleficence might be resolved by recognizing that adverse effects have no clear black or white “truth.” This essay suggests a pragmatic approach for providers to minimize nocebo responses while still maintaining patient autonomy through “contextualized informed consent,” which takes into account possible side effects, the patient being treated, and the particular diagnosis involved. (shrink)

This paper aims to critique the phenomenon of advanced patient autonomy and choice in healthcare within the specific context of self-testing devices. A growing number of self-testing medical devices are currently available for home use. The premise underpinning many of these devices is that they assist individuals to be more autonomous in the assessment and management of their health. Increased patient autonomy is assumed to be a good thing. We take issue with this assumption and argue that self-testing provides a (...) specific example how increased patient autonomy and choice within healthcare might not best serve the patient population. We propose that current interpretations of autonomy in healthcare are based on negative accounts of liberty to the detriment of a more relational understanding. We also propose that Kantian philosophy is often applied to the healthcare arena in an inappropriate manner. We draw on the philosophical literature and examples from the self-testing process to support these claims. We conclude by offering an alternative account of autonomy based on the interrelated concepts of relationality, care and responsibility. (shrink)

I will consider how we can assess the interests of critically ill children who will survive only while aggressive medical support is continued. If aggressive medical support is withdrawn, the child will die shortly afterwards. This is important because when the courts are asked to decide treatments, the standard is that decisions should be made in the best interests of the child. My claim is that this is not a coherent way to consider how some children in this situation should (...) be treated. I will consider two separate aspects of this problem. First, I will argue that there is no objective best interests test and no immediate prospect that we will be able to develop one. Secondly, I will argue that best interests are not a coherent way to consider the interests of children who will die shortly after treatment is withdrawn. To reinforce this claim, I will describe an example of two children where acting in the child's best interests produces counter-intuitive conclusions. (shrink)

In this paper we argue that while individual private interests such as autonomy and the need for a medical procedure or treatment are important in the provision and delivery of health care and the utilization of biotechnologies, these concepts need to be balanced with other interests such that in certain situations they do not take priority. We use as an example a particular developing biotechnology, xenotransplantation, to suggest that interest in the health of the public is such that this biotechnology (...) should not be permitted to move to the clinical trial stage because of the particular risk of harm it poses to the potential xeno-recipient, their close contacts and the wider population. This is despite the interest of those in need of a transplant in allowing such clinical trials to proceed. We derive support for our position from John Stuart Mill's harm principle. (shrink)

There are three lines of argument in defence of coercive treatment of patients with mental disorders: arguments regarding (1) societal interests to protect others, (2) the patients' own health interests, and (3) patient autonomy. In this paper, we analyse these arguments in relation to an idealized case, where a person with a mental disorder claims not to want medical treatment for religious reasons. We also discuss who should decide what in situations where patients with mental disorders deny treatment on seemingly (...) rational grounds.We conclude that, in principle, coercive treatment cannot be defended for the sake of protecting others. While coercive actions can be acceptable in order to protect close family and others, medical treatment is not justified for such reasons but should be given only in the interest of patients. Coercive treatment may be required in order to promote the patient's health interests, but health interests have to waive if they go against the autonomous interests of the patient. We argue that non-autonomous patients can have reasons, rooted in their deeply-set values, to renounce compulsory institutional treatment, and that such reasons should be respected unless it can be assumed that their new predicaments have caused them to change their views. (shrink)

The administration of pro re nata medications is the responsibility of the nurse. However, ethical uncertainties often happen due to the inability of incapacitated patients to collaborate with the nurse in the process of decision making for pro re nata medication administration. There is a lack of integrative knowledge and insufficient understanding regarding ethical considerations surrounding the administration of pro re nata medications to incapacitated patients. Therefore, they have been discussed in this paper and practical strategies to avoid unethical practices (...) have been suggested. The complicated caring situation surrounding the administration of pro re nata medications is intertwined with ethical issues affecting the consideration of the patient's wishes and interventions that override them. The patient's right of autonomy and treatment refusal, surrogacy role, paternalism, and coercion are the main ethos of ethical pro re nata medication administration. Education and training can help nurses avoid legal and ethical issues in pro re nata medicines management and improve the quality and safety of healthcare. Empirical research is needed to improve our understanding of this phenomenon in the multidisciplinary environment of medicines management. (shrink)

Accounts of the value of patient choice in contemporary medical ethics typically focus on the act of choosing. Being the one to choose, it is argued, can be valuable either because it enables one to bring about desired outcomes, or because it is a way of enacting one’s autonomy. This paper argues that all such accounts miss something important. In some circumstances, it is having the opportunity to choose, not the act of choosing, that is valuable. That is because in (...) many situations whether one has, or is denied, that opportunity conveys how one is seen. In particular, it conveys whether or not one is seen as an equal and competent member of society. Adequately recognising this fact has implications for what healthcare professionals should do, ones that require a move away from the current focus on autonomy. The paper draws out these implications by focusing on patients who may struggle to be recognised as competent and equal members of society, and whose autonomy may thus itself sometimes be in question. (shrink)