Different judgments by Christian communities on issues in sexual ethics involve different weightings of various sources of moral authority, different understandings of the normativity of the natural, and different assessments of the scope of freedom to be exercised in relation to the goods of marriage. These fundamental differences of interpretation can be exemplified by the ongoing Roman Catholic discussion of the legitimacy of voluntary sterilization in certain “hard cases.” The contributors to this issue of Christian Bioethics, in their spirited exchange (...) on that issue, exemplify the need for careful attention to the ways that differences of theological emphasis and moral method lead to different judgments in particular cases, both within and between particular Christian communities. (shrink)

The attempt to critique the profession of clinical ethics consultation by establishing the impossibility of ethics expertise has been a red herring. Decisions made in clinical ethics cases are almost never based purely on moral judgments. Instead, they are all-things-considered judgments that involve determining how to balance other values as well. A standard of justified decision-making in this context would enable us to identify experts who could achieve these standards more often than others, and thus provide a basis for expertise (...) in clinical ethics consultation. This expertise relies in part on what Richard Zaner calls the “expert knowledge of ethical phenomena”. (shrink)

The varieties of meaning in which we use the terms illness and health requires that we develope a conceptualization allowing us to maintain a unity between the differences. In fact, the experiences of health and illness are complex ones and they need to be understood in their different levels so that the need for help of patients and their desire for health is adequately faced. At its roots, the experience of illness is that of a threat posed to the unreflective (...) credit given to life in good health. This threat has not only a biopsychosocial dimension, but a moral and sybolic one as well, and it is mainly at this level that illness represents a moral challenge. Contemporary culture seems to be at pains in suggesting a shared set of meanings enabling the patient to give an intersubjectively valid sense of illness, since the only kind of answer offered is a technical one. The symbolic dimension of the notions of health and illness call for a deeper cultural enterprise of looking for a credible sense of illness for our times. (shrink)

Douglas Diekema has argued that it is not the best interest standard, but the harm principle that serves as the moral basis for ethicists, clinicians, and the courts to trigger state intervention to limit parental authority in the clinic. Diekema claims the harm principle is especially effective in justifying state intervention in cases of religiously motivated medical neglect in pediatrics involving Jehovah’s Witnesses and Christian Scientists. I argue that Diekema has not articulated a harm principle that is capable of justifying (...) state intervention in these cases. Where disagreements over appropriate care are tethered to metaphysical disagreements, it is moral-metaphysical standards, rather than merely moral standards, that are needed to provide substantive guidance. I provide a discussion of Diekema’s harm principle to the broader end of highlighting an inconsistency between the theory and practice of secular bioethics when overriding religiously based medical decisions. In a secular state, ethicists, clinicians, and the courts are purportedly neutral with respect to moral-metaphysical positions, especially regarding those claims considered to be religious. However, the practice of overriding religiously based parental requests requires doffing the mantle of neutrality. In the search for a meaningful standard by which to override religiously based parental requests in pediatrics, bioethicists cannot avoid some minimal metaphysical commitments. To resolve this inconsistency, bioethicists must either begin permitting religiously based requests, even at the cost of children’s lives, or admit that at least some moral-metaphysical disputes can be rationally adjudicated. (shrink)

In ethics, the use of empirical data has become more and more popular, leading to a distinct form of applied ethics, namely empirical ethics. This ‘empirical turn’ is especially visible in bioethics. There are various ways of combining empirical research and ethical reflection. In this paper we discuss the use of empirical data in a special form of Reflective Equilibrium (RE), namely the Network Model with Third Person Moral Experiences. In this model, the empirical data consist of the moral experiences (...) of people in a practice. Although inclusion of these moral experiences in this specific model of RE can be well defended, their use in the application of the model still raises important questions. What precisely are moral experiences? How to determine relevance of experiences, in other words: should there be a selection of the moral experiences that are eventually used in the RE? How much weight should the empirical data have in the RE? And the key question: can the use of RE by empirical ethicists really produce answers to practical moral questions?In this paper we start to answer the above questions by giving examples taken from our research project on understanding the norm of informed consent in the field of pediatric oncology. We especially emphasize that incorporation of empirical data in a network model can reduce the risk of self‐justification and bias and can increase the credibility of the RE reached. (shrink)

Erratum to: Echo Calling Narcissus: What Exceeds the Gaze of Clinical Ethics Consultation? Content Type Journal Article Pages 171-171 DOI 10.1007/s10730-010-9132-7 Authors Jeffrey P. Bishop, Saint Louis University Tenet Chair of Health Care Ethics, Albert Gnaegi Center for Health Care Ethics Salus Center, Room 527, 3545 Lafayette Ave St. Louis MO 63104-1314 USA Joseph B. Fanning, Vanderbilt University Center for Biomedical Ethics and Society 2525 West End Ave., 4th Floor, Suite 400 Nashville TN 37203 USA Mark J. Bliton, Vanderbilt University (...) Center for Biomedical Ethics and Society 2525 West End Ave., 4th Floor, Suite 400 Nashville TN 37203 USA Journal HEC Forum Online ISSN 1572-8498 Print ISSN 0956-2737 Journal Volume Volume 22 Journal Issue Volume 22, Number 2. (shrink)

As a practicing physician (psychiatrist), scientist (neurologist) and philosopher, Erwin Straus developed a body of writing which, falling within the phenomenological tradition, is highly original and insightful. His unusual combination of work from these three areas constitutes one of the most important attempts to provide what has been called a new Paideia. Regarding this unique blend of perspectives and concerns as quite natural, he conceived his work variously as a medical anthropologyrdquo; or phenomenological psychology. In the end, he was both (...) a pioneer and a rebel: starting from psychiatry, he proceeded boldly straight into phenomenological philosophy, illuminating significant aspects of human life: if we would understand the norm, we must begin with the disruptions, as failures of existential projects; that is, as forms of human life - which was ultimately at the heart of his life-long epistemic and therapeutic concerns. (shrink)

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

Baylis, Tomlinson, and Hoffmaster each raise a number of critiques in response to Bliton's manuscript. In response, we focus on three themes we believe run through each of their critiques. The first is the ambiguity between the role of ethics consultation within an institution and the role of the actual ethics consultant in a particular situation, as well as the resulting confusion when these roles are conflated. We explore this theme by revisiting the question of What's going on? in clinical (...) ethics consultations. Moving from those issues associated with the role of the ethics consultant to those associated with the role of inquiry within the practice of ethics consultation, we then take up the serious challenge that Bliton seems shackled by the assumptions and institutional dispositions embedded in the medical culture in which he is working. This reveals the second theme, namely that there is a risk of co-optation when acting in a role that derives its legitimacy from institutional sources. Finally, we focus on an even more problematic implication stemming from the first two, namely that the focus on institutional power as the crucial factor for determining ethical significance has the effect of distorting, and perhaps obscuring, other forms of relational, interpersonal, and moral meaning. (shrink)

This paper is prompted by the charge that the prevailing Western paradigm of medical knowledge is essentially Cartesian. Hence, illness, disease, disability, etc. are said to be conceived of in Cartesian terms. The paper attempts to make use of the critique of Cartesianism in medicine developed by certain commentators, notably Leder (1992), in order to expose Cartesian commitments in conceptions of disability. The paper also attempts to sketch an alternative conception of disability — one partly inspired by the work of (...) Merleau-Ponty. In particular, three key Cartesian claims are identified and subjected to criticism. These are as follows: (a) The claim that the body is an object, (b) what is termed here ‘the modularity thesis’, and (c) the claim that the body cannot be constitutive of the self (i.e. since the soul/mind/brain is). In opposition to these claims, it is argued that the body is properly viewed as a subject; that there are neither purely mental, nor purely physical disabilities; and that selves are constituted, at least in part, by their bodies. (shrink)

The American Journal of Bioethics, Volume 12, Issue 2, Page 26-27, February 2012.

While many have suggested that to withdraw medical interventions is ethically equivalent to withholding them, the moral complexity of actually withdrawing life supportive interventions from a patient cannot be ignored. Utilizing interplay between expository and narrative styles, and drawing upon our experiences with patients, families, nurses, and physicians when life supports have been withdrawn, we explore the changeable character of boundaries in end-of-life situations. We consider ways in which boundaries imply differences – for example, between cognition and performance – and (...) how the encounter with boundaries can generate altered meanings important for understanding decisions and actions in these contexts. We conclude that the reliance on mere roles to support the moral weight of withdrawing medical interventions is inadequate. Roles that lead us to such moments are exceeded by the responsibility encountered in such moments. And here, we suggest, is the momentous character of withdrawal: it presents the grave astonishment, the trembling awe, in the not-being-there of the other in death. (shrink)

Some critiques of cybermedicine claim that it is problematic because it fails to create physician–patient relationships. But, electronically mediated encounters do create such relationships. The issue is the nature and quality of those relationships and whether they are conducive to good patient care and meet the ethical ideals and standards of medicine. In this paper, I argue that effective communication and compassion are, in most cases, necessary for the establishment of trusting and morally appropriate physician–patient relationships. The creation of these (...) relationships requires patients and physicians to take psychological and emotional risks and to make commitments to each other. The problem is that by altering the form and content of verbal and non-verbal behaviors and by limiting the kinds of interactions that can take place, cybermedicine makes risk-free interactions easier and more commonplace and retards the development of physician compassion and patient trust. In doing so, cybermedicine encourages morally inappropriate physician–patient relationships. I argue that Merleau-Ponty''s notion of embodiment and Kierkegaard''s criticisms of disinterested reflection help us to understand how cybermedicine can undermine patient health and well being and why it should be seen as a possible threat to the moral integrity of physician–patient relationships. (shrink)

Abstract“Clinical ethics consultants” have been practicing in the United States for about 50 years. Most of the earliest consultants—the “pioneers”—were “outsiders” when they first appeared at patients' bedsides and in the clinic. However, if they were outsiders initially, they acclimated to the clinical setting and became “insiders” very quickly. Moreover, there was some tension between traditional academics and those doing applied ethics about whether there was sufficient “critical distance” for appropriate reflection about the complex medical ethics dilemmas of the day (...) if one were involved in the decision making. Again, the pioneers deflected concerns by identifying and instituting safeguards to assure professional objectivity in clinical ethics consultation services. One might suggest that in moving inside and establishing normative practices, the pioneer clinical ethics consultants anticipated adoption of their routines and professionalization of the field. (shrink)

The past few years have seen greater attention directed toward important procedural elements associated with ethics consultation. Examples include considerations about how best to document consulta...

Definition of the problem: Ethics consultation is one of the most important ways in which clinical ethicists can support both health-care providers and patients and their relatives in coping with ethical and existential challenges. The practice of ethics consultation, as performed at the Freiburg University Hospital is described and illustrated by a case report about the problem of treatment termination. The range of subject matters that come up in ethics consultations is analyzed. A research program in clinical ethics is summarized (...) that has been undertaken to pave the way for a specific and interdisciplinary analysis of needs; from there on, the investigation aims at further developing clinical ethics support services. Suggestions for criteria of competence for ethics consultants are formulated on the basis of both the author’s and international work. Finally, the issues of structural conditions for establishing clinical ethics in the German-speaking world are raised and the long-term prospect of ethics consultation as an instrument for learning and teaching ethics in the health-care system is highlighted. (shrink)

This essay focuses on questions central to Husserl’s essential methodology, specifically his notion of ‘free-fantasy variation,’ which he regarded as his ‘fundamental methodological insight.’ At the heart of this ‘vital element of phenomenology’ is what he often terms ‘as-if experience’ thanks to which anything whatever can be considered either for its own sake or as an example of something else. Further analysis explores the act of exemplification, the act of feigning and the shifts of attention and orientation that ground free-fantasy (...) variation. Exemplification and possibilizing are then examined in daily life to discern what makes the complex act of feigning at all possible. An examination of the phenomenon of upsets brings the core sense of possibilizing to light. A focus on the dramatic force intrinsic to these experiences, and the essential place of reflective awareness inherent to them, makes apparent how the rudimentary sense of self begins to emerge, and there follows an analysis of this self-referentiality of possibilizing. The analysis then concludes with a brief examination of Husserl’s so-called ‘zig-zag’ method of constitutive phenomenology. (shrink)

In this paper I explicate what it means to see phenomenologically for an able-bodied researcher in the field of disability, and how this seeing yields a non-reductionistic understanding of the phenomenon of disability. My aim is to show how in this context, I, as a human and social scientist can use phenomenological methodology for both collecting and interpreting data. Though phenomenological philosophy can provide the basis of social scientific epistemology, it does not lend itself easily to a single specific or (...) programmatic social scientific methodology. I offer possible ways of using phenomenological theory, methodology and techniques in order to understand the experience of a person with physical disability learning to use a wheelchair. I use data from a clinical encounter between a physical therapist (PT) and an adult with Spinal Cord Injury (SCI) in an inpatient rehabilitation hospital in Midwestern United States in order to flesh out phenomenological seeing. I conclude with implications for qualitative researchers who use phenomenological methods to inform their work. (shrink)

(2003). The Ethics and Governance of Medical Research: What does regulation have to do with morality? New Review of Bioethics: Vol. 1, No. 1, pp. 41-58.

This essay considers Richard Zaners storytelling in Troubled Voices as a form of possibilizing which uses the stories to exemplify important moral themes such as contingency and freedom. Distinguishing between activities of moral discovery through the telling of a story and posing in the sense of writing to tell the moral of the story, I suggest that something crucial goes on for Zaner in his own tellings. Several of the more insistent implications Zaner reveals about the moral relationships encountered in (...) the activity of clinical ethics consultation are examined in that light, especially regarding this question: is it more beneficial, or harmful, to articulate elements of core meanings and values that are entailed in individual viewpoints, which, prior to an ethics consultants participation, may have remained unspoken and possibly unacknowledged? (shrink)

Significant challenges arise for clinical care teams when a patient or surrogate decision-maker hopes a miracle will occur. This article answers the question, “How should clinical bioethicists respond when a medical decision-maker uses the hope for a miracle to orient her medical decisions?” We argue the ethicist must first understand the complexity of the miracle-invocation. To this end, we provide a taxonomy of miracle-invocations that assist the ethicist in analyzing the invocator's conceptions of God, community, and self. After the ethicist (...) appreciates how these concepts influence the invocator's worldview, she can begin responding to this hope with specific practices. We discuss these practices in detail and offer concrete recommendations for a justified response to the hope for a miracle. (shrink)

After a brief, personal reflection on Aron Gurwitsch's life and his many influences on my career, I devote this lecture to some of the central themes of a phenomenology of medicine. Its core is the clinical encounter, which displays a certain structure I term the asymmetry of power and vulnerability —a complex contextual imbalance characterized by multiple points of view, hence points for reflective entrance. These are then interpreted phenomenologically in terms of epoché and reduction, evidence, reflection, and other related (...) themes. I conclude with a suggestion about "the fundamental method" of phenomenology, free fantasy variation. (shrink)

This essay introduces a thematic issue focused on the contributions to clinical ethics and the philosophy of medicine by Richard M. Zaner. We consider the apparent divorce of Zaners philosophical roots from his recent narrative immersions into the blooming, buzzing confusions of clinical-moral lifeworlds. Our considerations of the Zanerian context and origins of the clinical encounter introduce the fundamental questions faced by Zaner and his commentators in this issue, questions about the role of ethics consultants, moral authority, and clinical truths.

This paper provides a brief overview and critique of the dominant objectivist understanding and use of illness narrative in Enlightenment (scientific) medicine and ethics, as well as several revisionist accounts, which reflect the evolution of this approach. In light of certain limitations and difficulties endemic in the objectivist understanding of illness narrative, an alternative phronesis approach to medical ethics influenced by Charles Taylor’s account of the interpretive nature of human agency and language is examined. To this end, the account of (...) interpretive medical responsibility previously described by Schultz and Carnevale as "clinical phronesis" (based upon Taylor’s notion of "strong" or "radical evaluation") is reviewed and expanded. The thesis of this paper is that illness narrative has the ability to benefit patients as well as the potential to cause harm or iatrogenic effects. This benefit or harm is contingent upon how the story is told and understood. Consequently, these tales are not simply "nice stories," cathartic gestures, or mere supplements to scientific procedures and decision making, as suggested by the objectivist approach. Rather, they open the agent to meanings that provide a context for explanation and evaluation of illness episodes and therapeutic activities. This understanding provides indicators (guides) for right action. Hence, medical responsibility as clinical phronesis involves, first, the patient and provider’s coformulation and cointerpretation of what is going on in the patient’s illness narrative, and second, the patient and provider’s response to interpretation of the facts of illness and what they signify–not simply a response to the brute facts of illness, alone. The appeal to medical responsibility as clinical phronesis thus underscores the importance of getting the patient’s story of illness right. It is anticipated that further elaboration concerning the idea of clinical phronesis as interpretive illness narrative will provide a new foundation for medical ethics and decision making. (shrink)

This paper discusses the importance of Richard M. Zaners work on clinical ethics for answering the question: what kind of doing is ethics consultation? The paper argues first, that four common approaches to clinical ethics – applied ethics, casuistry, principlism, and conflict resolution – cannot adequately address the nature of the activity that makes up clinical ethics; second, that understanding the practical character of clinical ethics is critically important for the field; and third, that the practice of clinical ethics is (...) bound up with the normative commitments of medicine as a therapeutic enterprise. (shrink)

This article argues for the importance of theoreticalreflections that originate from patients' experiences.Traditionally academic philosophers have linked their ability totheorize about the moral basis of medical practice to their roleas outside observer. The author contends that recently a new typeof reflection has come from within particular patientpopulations. Drawing upon a distinction created by AntonioGramsci, it is argued that one can distinguish the theorygenerated by traditional bioethicists, who are academicallytrained, from that of ``organic'' bioethicists, who identifythemselves with a particular patient community. (...) Thecharacteristics of this new type of bioethicist that are exploredin this article include a close association of memoir andphilosophy, an interrelationship of theory and praxis, and anintimate connection between the individual and a particularpatient community. (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)

It was in the course of one particular clinical encounter that I came to realize the power of narrative, especially for expressing clinically presented ethical matters. In Husserlian terms, the mode of evidence proper to the unique and the singular is the very indirection that is the genius of story-telling. Moreover, the clinical consultant is unavoidably changed by his or her clinical involvement. The individuals whose situation is at issue have their own stories that need telling. Clinical ethics is in (...) this sense a way of helping patients, families, and, yes, health providers to discover and give voice to those stories. In this way, clinical ethics is an evoking of meaning. Kierkegaard understood this well: Indirect communication is the language for the unique and the otherwise inexpressible. (shrink)

In this article I scrutinize the question whetherclinical medicine, in order to be considered ahermeneutical enterprise, must be thought of as areading of different texts. Three differentproposals for a definition of the concept of text inmedicine, suggested by other hermeneuticians, arediscussed. All three proposals are shown to beunsatisfying in various ways. Instead of attempting tofind a fourth definition of the concept of textsuitable to a hermeneutics of medicine, I then try toshow that the assumption that one needs to operatewith the (...) concept of text in order to develop ahermeneutics of medicine is false. Clinicalinterpretation can be shown to essentially consist ina dialogical hermeneutics, the pattern of which can befound in the philosophy of Hans-Georg Gadamer. Thiskind of hermeneutics is not a methodology of textreading, but an ontological, phenomenologicalhermeneutics in which understanding is a necessaryfeature of the being-together of human beings in theworld. This being-together in and through languagetakes on a peculiar form in the clinical encounter,since the medical meeting is typically characterizedby an asymmetrical enstrangement and has a specificgoal – health for the patient – absent in other formsof hermeneutics. Central issues of Gadamer''sphilosophy, e.g. fusion of horizons, are shown tofit the structure of clinical practice. (shrink)

Guiding our response in this essay is our view that current efforts to demarcate the role of the clinical ethicist risk reducing its complex network of authorizations to sites of power and payment. In turn, the role becomes susceptible to various ideologies—individualisms, proceduralisms, secularisms—that further divide the body from the web of significances that matter to that body, where only she, the patient, is located. The security of policy, standards, and employment will pull against and eventually sever the authorization secured (...) by authentic moral inquiry. Instead of asking “What do I need to know?”, the question animating the drive to standardize will be “What is the policy or standard?” The claims of the authors in this issue of HEC Forum confirm these suspicions. (shrink)

Bioethicists have recently expressed concern over a lack of quality control within the field. This apprehension focuses on bioethics expanding in ways that obscure its distinctive ethical remit and the specialist reasoning skills it requires. This thesis about the quality and conduct of bioethics may have particular relevance for clinical ethics. As one of the youngest offshoots of bioethics, the field focuses on the ethical issues that arise specifically in a clinical context. However, non-ethics specialists are increasingly involved in this (...) field. This means that clinical ethics could be especially vulnerable to the quality control concerns articulated within bioethics. The growing public profile of clinical ethics means that concerns over quality in this area warrant specific attention by those concerned with declining standards in bioethics and those working in clinical ethics. (shrink)

A specific clinical encounter in which the author was an ethics consultant, after a brief summary, provides the basis for a phenomenological delineation and explication of the key ingredients of such encounters. A brief historical reflection on the myths of Gyges and Aesculapius suggests that several of these ingredients are essential to clinical encounters and help constitute their specific moral aspects and challenges. Understood as an interpersonal relationship framed by critical issues of illness experiences, the clinical encounter makes prominent such (...) constitutive features as dialogue, trust, violence, and especially vulnerability and power. The role of the clinical ethicist is found to be often critical in these encounters, in particular because of the need to help patients and doctors identify, understand, and cope productively with fundamental moral phenomena. (shrink)

After expressing gratitude to each contributor, and briefly commenting on each, I probe several main themes of my work, addressing the question of the apparent difference between my earlier philosophical and later clinical writings. Central to both is the reflexivity of the human agent, and that each exhibits a form of practice regardless of the specific aims embedded in each. I then address the theme of narrative writing as my work has developed over the past several decades – at the (...) heart of which are questions of self and integrity. (shrink)

‘Doing good medical ethics’ involves attending to both the biomedical and existential aspects of illness. For this, we need to bring in a phenomenological perspective to the clinical encounter, adopt a virtue-based ethic and resolve to re-evaluate the goals of medicine, in particular the alleviation of suffering and the role of compassion in everyday ethics.

In an overview of the essays in this project, a number of clinical ethics issues receive emphasis. (1) One cluster concerns the ethical concerns presented within the relationship between the providers (doctor, nurse, etc.) and patient (and family), as distinct from those associated with being a clinical ethics consultant invited into a situation to assist. (2) Distinct from these are ethical issues intrinsic to the ways in which clinical encounters are variously written about (from chart notes to published articles). (3) (...) Finally, there is a set of issues connected with the major characteristics of clinical encounters, in view of which it is imperative to be specifically attentive to the fine details and complex interactions among patient, doctor, family, and others, within a specific social context. Keeping these matters in mind helps to clarify the differences between consulting (talking and listening) and writing about consultations, as well as among the various kinds of writing about clinical encounters. (shrink)

In their article “Moral Hazards in Pediatrics” (2016), Brunnquell and Michaelson remind us that the child's perspective is of utmost importance when making health care decisions and express concern...