A liberal society seeks not to impose a single way of life, but to leave its citizens as free as possible to choose their own values and ends. It therefore must govern by principles of justice that do not presuppose any particular vision of the good life. But can any such principles be found? And if not, what are the consequences for justice as a moral and political ideal? These are the questions Michael Sandel takes up in this penetrating critique (...) of contemporary liberalism. Sandel locates modern liberalism in the tradition of Kant, and focuses on its most influential recent expression in the work of John Rawls. In the most important challenge yet to Rawls' theory of justice, Sandel traces the limits of liberalism to the conception of the person that underlies it, and argues for a deeper understanding of community than liberalism allows. (shrink)

Despite its title, Alan Wertheimer’s new book is not another tiresome exploration of Marxist economic theories. Indeed, there is virtually no extended discussion of Marxism at all, since Wertheimer believes that what is unique to that perspective is highly problematic, given that when Marxists simply assert that capitalists do exploit wage laborers they are appealing to “the ordinary notion that one party exploits another when it gets unfair and undeserved benefits from its transactions or relationships with others”. His goal is (...) to analyze this ordinary sense of exploitation, to explore in detail some of the many forms it can take, and to begin some serious thinking about what he terms its moral weight and its moral force. This groundbreaking work, the first book-length treatment of its subject from a broadly analytic standpoint, should do much to disabuse non-Marxist philosophers of the notion that exploitation is largely peripheral to the central questions of moral and political philosophy. (shrink)

Contemporary research ethics policies started with reflection on the atrocities perpetrated upon concentration camp inmates by Nazi doctors. Apparently, as a consequence of that experience, the policies that now guide human subject research focus on the protection of human subjects by making informed consent the centerpiece of regulatory attention. I take the choice of context for policy design, the initial prioritization of informed consent, and several associated conceptual missteps, to have set research ethics off in the wrong direction. The aim (...) of this paper is to sort out these confusions and their implications and to offer instead a straightforward framework for considering the ethical conduct of human subject research. In the course of this discussion I clarify different senses of autonomy that have been confounded and present more intelligible justifications for informed consent. I also take issue with several of the now accepted dogmas that govern research ethics. These include: the primacy of informed consent, the protection of the vulnerable, the substitution of beneficence for research's social purpose, and the introduction of an untenable distinction between innovation and research. (shrink)

A predominant ethical view holds that physician‐investigators should conduct their research with therapeutic intent. And since a physician offering a therapy wouldn't prescribe second‐rate treatments, the experimental intervention and the best proven therapy should appear equally effective. "Clinical equipoise" is necessary. But this perspective is flawed. The ethics of research and of therapy are fundamentally different, and clinical equipoise should be abandoned.

Public health ethics, like the field of public health it addresses, traditionally has focused more on practice and particular cases than on theory, with the result that some concepts, methods, and boundaries remain largely undefined. This paper attempts to provide a rough conceptual map of the terrain of public health ethics. We begin by briefly defining public health and identifying general features of the field that are particularly relevant for a discussion of public health ethics.Public health is primarily concerned with (...) the health of the entire population, rather than the health of individuals. Its features include an emphasis on the promotion of health and the prevention of disease and disability; the collection and use of epidemiological data, population surveillance, and other forms of empirical quantitative assessment; a recognition of the multidimensional nature of the determinants of health; and a focus on the complex interactions of many factors—biological, behavioral, social, and environmental—in developing effective interventions. (shrink)

Public health ethics in the future will be distinguished from public health ethics in the past by this new subfield being labeled as such, acknowledged, and called upon for service. Ethical dilemmas have been present throughout the history of public health. The question of whether to force Henning Jacobson to be immunized in 1905 in accordance with the 1902 Massachusetts smallpox vaccination law was one of ethics as well as law. How Thomas Parran, Surgeon General in 1936, chose to respond (...) to a raging syphilis epidemic in the United States in the early part of the 2W century raised considerable moral debate in determining the appropriate public health response for a government? More recently, questions have arisen concerning the appropriate reach of government in controlling HIV banning smoking, or promoting healthy lifestyles. Debates over government infringement, morality, and justice recur throughout the history of public health. (shrink)

Biomedical research is so important that there is a positive moral obligation to pursue it and to participate in itScience is under attack. In Europe, America, and Australasia in particular, scientists are objects of suspicion and are on the defensive.i“Frankenstein science”5–8 is a phrase never far from the lips of those who take exception to some aspect of science or indeed some supposed abuse by scientists. We should not, however, forget the powerful obligation there is to undertake, support, and participate (...) in scientific research, particularly biomedical research, and the powerful moral imperative that underpins these obligations. Now it is more imperative than ever to articulate and explain these obligations and to do so is the subject and the object of this paper.Let me present the question in its starkest form: is there a moral obligation to undertake, support and even to participate in serious scientific research? If there is, does that obligation require not only that beneficial research be undertaken but also that “we”, as individuals and “we” as societies be willing to support and even participate in research where necessary?Thus far the overwhelming answer given to this question has been “no”, and research has almost universally been treated with suspicion and even hostility by the vast majority of all those concerned with the ethics and regulation of research. The so called “precautionary approach”9 sums up this attitude, requiring dangers to be considered more likely and more serious than benefits, and assuming that no sane person would or should participate in research unless they had a pressing personal reason for so doing, or unless they were motivated by a totally impersonal altruism. International agreements and protocols—for example, the Declaration of Helsinki10 and the CIOMS Guidelines11—have been directed principally at …. (shrink)

Although for the last 50 years, ethicists dealing with human experimentation have focused primarily on the need to protect individual research subjects and vulnerable groups, biomedical research, especially in genetics, now requires the establishment of standards for the protection of communities. We have developed such a strategy, based on five steps. (i) Identification of community characteristics relevant to the biomedical research setting, (ii) delineation of a typology of different types of communities using these characteristics, (iii) determination of the range of (...) possible community protections, (iv) creation of connections between particular protections and one or more community characteristics necessary for its implementation, and (v) synthesis of community characteristics and possible protections to define protections appropriate for each type of community. Depending on the particular community, consent and consultation, consultation alone, or no added protections may be required for research. (shrink)

A liberal society seeks not to impose a single way of life, but to leave its citizens as free as possible to choose their own values and ends. It therefore must govern by principles of justice that do not presuppose any particular vision of the good life. But can any such principles be found? And if not, what are the consequences for justice as a moral and political ideal? These are the questions Michael Sandel takes up in this penetrating critique (...) of contemporary liberalism. Sandel locates modern liberalism in the tradition of Kant, and focuses on its most influential recent expression in the work of John Rawls. In the most important challenge yet to Rawls' theory of justice, Sandel traces the limits of liberalism to the conception of the person that underlies it, and argues for a deeper understanding of community than liberalism allows. (shrink)

Contemporary research ethics policies started with reflection on the atrocities perpetrated upoconcentration camp inmates by Nazi doctors. Apparently, as a consequence of that experience, the policies that now guide human subject research focus on the protection of human subjects by making informed consent the centerpiece of regulatory attention. I take the choice of context for policy design, the initial prioritization of informed consent, and several associated conceptual missteps, to have set research ethics off in the wrong direction. The aim of (...) this paper is to sort out these confusions and their implications and to offer instead a straightforward framework for considering the ethical conduct of human subject research. In the course of this discussion I clarify different senses of autonomy that have been confounded and present more intelligible justifications for informed consent. I also take issue with several of the now accepted dogmas that govern research ethics. These include: the primacy of informed consent, the protection of the vulnerable, the substitution of beneficence for research's social purpose, and the introduction of an untenable distinction between innovation and research. (shrink)

The issue of the protection of communities in clinical research first arose 10 years ago in studies conducted in technologically developing countries by scientists from technologically developed nations. The question was, which ethical standards ought to apply, those of the Western investigators or local standards?

Trial participation in the proposed HIV Vaccine Trials in South Africa is discussed in the context of the ethical tension that exists between international ethical research standards and local standards of care and cultural norms in the Third World. The important concepts of informed consent, risk-benefit ratio and fair treatment of trial participants are interpreted differently in traditional, rural African communities, where a moderate form of communitarianism referred to as "Ubuntu" or "communalism" is still prevalent. Research is an altruistic endeavor (...) that benefits communities and societies as a result of risks taken by individuals. Universal ethical guidelines that are highly individualistic and fail to emphasize communalism may represent serious problems for the sort of research needed in Africa today. (shrink)

In analyzing the obstacles to democratization in post- independence Africa, Mahmood Mamdani offers a bold, insightful account of colonialism's legacy--a bifurcated power that mediated racial domination through tribally organized local authorities, reproducing racial identity in citizens and ethnic identity in subjects. Many writers have understood colonial rule as either "direct" (French) or "indirect" (British), with a third variant--apartheid--as exceptional. This benign terminology, Mamdani shows, masks the fact that these were actually variants of a despotism. While direct rule denied rights to (...) subjects on racial grounds, indirect rule incorporated them into a "customary" mode of rule, with state-appointed Native Authorities defining custom. By tapping authoritarian possibilities in culture, and by giving culture an authoritarian bent, indirect rule (decentralized despotism) set the pace for Africa; the French followed suit by changing from direct to indirect administration, while apartheid emerged relatively later. Apartheid, Mamdani shows, was actually the generic form of the colonial state in Africa. Through case studies of rural (Uganda) and urban (South Africa) resistance movements, we learn how these institutional features fragment resistance and how states tend to play off reform in one sector against repression in the other. Reforming a power that institutionally enforces tension between town and country, and between ethnicities, is the key challenge for anyone interested in democratic reform in Africa. (shrink)

Ethical guidelines for conducting clinical trials have historically been based on a perceived therapeutic obligation to treat and benefit the patient-participants. The origins of this ethical framework can be traced to the Hippocratic oath originally written to guide doctors in caring for their patients, where the overriding moral obligation of doctors is strictly to do what is best for the individual patient, irrespective of other social considerations. In contrast, although medicine focuses on the health of the person, public health is (...) concerned with the health of the entire population, and thus, public health ethics is founded on the societal responsibility to protect and promote the health of the population as a whole. From a public health perspective, research ethics should be guided by giving due consideration to the risks and benefits to society in addition to the individual research participants. On the basis of a duty to protect the population as a whole, a fiduciary obligation to realise the social value of the research and the moral responsibility to distribute the benefits and burdens of research fairly across society, how a public health perspective on research ethics results in fundamental re-assessments of the proper course of action for two salient topical issues in research ethics is shown: stopping trials early for reasons of efficacy and the conduct of research on less expensive yet less effective interventions. (shrink)