Person-centred health care is increasingly endorsed as a key element of high-quality care, yet, in practice, it often means patient-centred health care. This book scrutinizes the principle of primacy of patient welfare, which, although deeply embedded in health professionalism, is long overdue for critical analysis and debate. It appears incontestable because patients have greater immediate health needs than clinicians and the patient-clinician encounter is often recognized as a moral enterprise as well as a service contract. However, Buetow argues that the (...) implication that clinician welfare is secondary can harm clinicians, patients and health system performance. Revaluing participants in health care as moral equals, this book advocates an ethic of virtue to respect the clinician as a whole person whose self-care and care from patients can benefit both parties, because their moral interests intertwine and warrant equal consideration. It then considers how to move from values including moral equality in health care to practice for people in their particular situations. Developing a genuinely inclusive concept of person-centred care accepting clinicians as moral equals it also facilitates the coalescence of patient-centred care and evidence-based health care. This reflective and provocative work develops a constructive alternative to the taken-for-granted principle of primacy of patient welfare. It is of interest to students and academics in the health and caring sciences, philosophy, ethics, medical humanities and health management.". (shrink)

“It's almost like putting salt in a wound, for this person who's already made a very difficult decision,” suggested Meghan Patterson, a licensed obstetrician-gynecologist whom we interviewed in our qualitative study of the experiences of North Carolina abortion providers practicing under the state's Woman's Right to Know Act. The act requires that women receive counseling with state-mandated information at least twenty-four hours prior to obtaining an abortion. After the law was passed, Patterson worked with clinic administrators, in consultation with a (...) lawyer, to write a script to be used in the state-mandated counseling procedure. She and her colleagues took particular steps to mitigate the effects of what she described as HB 854's “forced language”—such as referring to the “father of the child.” While HB 854 stipulated that patients must be informed of the medical risks associated with the particular abortion procedure as well as those of carrying the child to term, Patterson's script made explicit the magnitude of comparative risks, emphasizing that the risks of carrying a pregnancy to term are substantially greater than the risks of an early-term abortion. She felt that these contextualization strategies helped to facilitate trust and rapport in a clinical care situation that proved relationally and morally challenging. In this article, we take up and expand on this point by elucidating an empirically grounded approach to ethically justified care when health care providers face legal or institutional policy mandates that raise possible moral conflicts. Our approach builds on recent bioethics discourse addressing conscience in the practice of medicine. While the concept of conscience has broad philosophical underpinnings relating to moral judgment, agency, and discernments of right and wrong, debates in bioethics have tended to engage the concept primarily vis-à-vis rights of conscientious objection or refusal. Here, we suggest a broader frame for thinking about claims of conscience in health care. Our approach draws on the feminist bioethics and the ethics of care literatures to highlight how providers may be motivated by matters of conscience, including relational concerns, in the active provision of certain forms of care. What emerges are two possibilities: not only conscientious refusal to comply with a policy mandate but also conscientious compliance—working conscientiously within a mandate's confines. (shrink)

The ethical implications of the growth of for-profit health care institutions are complex. Two major moral criticisms of for-profit medicine are analyzed. The first claim is that for-profit health care institutions fail to fulfill their obligations to do their fair share in providing health care to the poor and so exacerbate the problem of access to health care. The second claim is that profit seeking in medicine will damage the physician-patient relationship, creating conflicts of interest that will diminish the quality (...) of care and erode patients' trust in their physicians and the public's trust in the medical profession. The authors conclude that while the continued expansion of for-profit health care may exacerbate in some respects problems of access, trust and conflicts of interest, it is a mistake to consider these problems as unique to for-profit health care; they are problems for not for-profit health care as well. Though these issues justify continuing moral concern, they do not at this time provide decisive grounds for substantially curbing or eliminating for-profit enterprise in health care. (shrink)

Opponents of conscience protections for Catholic Health Care institutions claim that, since institutions are not autonomous individuals, they are not subjects of conscience. Therefore, since institutional conscience does not exist, it does not deserve protection. In this article, the author demonstrates not only that institutional conscience exists but that it is an activity that pervades all human institutions. He provides a metaphysical sketch that illustrates how institutions are organic outgrowths of human social nature which mitigate the natural limitations of human (...) individuals. Consequently, the activity of conscience is inherently a component of the life of human institutions. (shrink)

The principle that physicians should always act in the best interests of the present patient is widely endorsed. At the same time, and often within the same document, it is recognised that there are appropriate exceptions to this principle. Unfortunately, little, if any, guidance is provided regarding which exceptions are appropriate and how they should be handled. These circumstances might be tenable if the appropriate exceptions were rare. Yet, evaluation of the literature reveals that there are numerous exceptions, several of (...) which pervade clinical medicine. This situation leaves physicians without adequate guidance on when to allow exceptions and how to address them, increasing the chances for unfairness in practice. The present article considers the range of exceptions, illustrates how the lack of guidance poses ethical concern and describes an alternative account of physician obligations to address this concern. (shrink)

Clinicians cannot obtain valid consent to treatment because they cannot guess which treatment option will serve a particular patient's best interests. These guesses could be made more accurately if patients were paired with providers who share their deep values.

The literature on conscience in medicine has paid little attention to what is meant by the word ‘conscience.’ This article distinguishes between retrospective and prospective conscience, distinguishes synderesis from conscience, and argues against intuitionist views of conscience. Conscience is defined as having two interrelated parts: (1) a commitment to morality itself; to acting and choosing morally according to the best of one’s ability, and (2) the activity of judging that an act one has done or about which one is deliberating (...) would violate that commitment. Tolerance is defined as mutual respect for conscience. A set of boundary conditions for justifiable respect for conscientious objection in medicine is proposed. (shrink)

: On the grounds that rape is an act of violence, not a natural act of intercourse, Roman Catholic teaching traditionally has permitted women who have been raped to take steps to prevent pregnancy, while consistently prohibiting abortion even in the case of rape. Recent scientific evidence that emergency contraception (EC) works primarily by preventing ovulation, not by preventing implantation or by aborting implanted embryos, has led Church authorities to permit the use of EC drugs in the setting of rape. (...) Doubts about whether an abortifacient effect of EC drugs has been completely disproven have led to controversy within the Church about whether it is sufficient to determine that a woman is not pregnant before using EC drugs or whether one must establish that she has not recently ovulated. This article presents clinical, epidemiological, and ethical arguments why testing for pregnancy should be morally sufficient for a faith community that is strongly opposed to abortion. (shrink)

Objective To explore attitudes towards conscientious objections among medical students in the UK. Methods Medical students at St George's University of London, Cardiff University, King's College London and Leeds University were emailed a link to an anonymous online questionnaire, hosted by an online survey company. The questionnaire contained nine questions. A total of 733 medical students responded. Results Nearly half of the students in this survey stated that they believed in the right of doctors to conscientiously object to any procedure. (...) Demand for the right to conscientiously object is greater in Muslim medical students when compared with other groups of religious medical students. Discussion Abortion continues to be a contentious issue among medical students and this may contribute to the looming crisis in abortion services over the coming years. This project sheds some light on how future doctors view some of their ethical rights and obligations. Using empirical evidence, it reveals that conscientious objection is an issue in the UK medical student body today. These data could help anticipate problems that may arise when these medical students qualify and practise medicine in the community. Conclusion Clearer guidance is needed for medical students about the issue of conscientious objection at medical school. (shrink)

One of the most vivid aspects of consciousness is the experience of emotion, yet this topic is given relatively little attention within consciousness studies. Emotions are crucial, for they provide quick and motivating assessments of value, without which action would be misdirected or absent. Emotions also involve linkages between phenomenal and intentional consciousness. This paper examines emotional consciousness from the standpoint of the representational theory of consciousness . Two interesting developments spring from this. The first is the need for the (...) representation of value, which is distinctive of emotional experience. The second is an extension of RTC’s theory of introspection to emotional states, revealing why emotional consciousness is so often introspective even though introspective abilities are not needed to experience emotions, and also explaining why introspection of emotional states is so much less reliable than that of other states of consciousness. (shrink)

In this companion volume to their 1981 work, A Philosophical Basis of Medical Practice, Pellegrino and Thomasma examine the principle of beneficence and its role in the practice of medicine. Their analysis, which is grounded in a thorough-going philosophy of medicine, addresses a wide array of practical and ethical concerns that are a part of health care decision-making today. Among these issues are the withdrawing and withholding of nutrition and hydration, competency assessment, the requirements for valid surrogate decision-making, quality-of-life determinations, (...) the allocation of scarce health care resources, medical gatekeeping, and for-profit medicine. The authors argue for the restoration of beneficence to its place as the fundamental principle of medical ethics. They maintain that to be guided by beneficence a physician must perform a right and good healing action which is consonant with the individual patient 's values. In order to act in the patient 's best interests, or the patient 's good, the physician and patient must discern what that good is. This knowledge is gained only through a process of dialogue between patient and/or family and physician which respects and honors the patient 's autonomous self-understanding and choice in the matter of treatment options. This emphasis on a dialogical discernment of the patient 's good rejects the assumption long held in medicine that what is considered to be the medical good is necessarily the good for this patient. In viewing autonomy as a necessary condition of beneficence, the authors move beyond a trend in the medical ethics literature which identifies beneficence with paternalism. In their analysis of beneficence, the authors reject the current emphasis on rights- and duty-based ethical systems in favor of a virtue-based theory which is grounded in the physician- patient relationship. This book's provocative contributions to medical ethics will be of great interest not only to physicians and other health professionals, but also to ethicists, students, patients, families, and all others concerned with the relationship of professional to patient and patient to professional in health care today. (shrink)

Conscientious objection has spurred impassioned debate in many Western countries. Some Norwegian general practitioners (GPs) refuse to refer for abortion. Little is know about how the GPs carry out their refusals in practice, how they perceive their refusal to fit with their role as professionals, and how refusals impact patients. Empirical data can inform subsequent normative analysis.

Conscience and Conscientious Objection of Health Care Professionals Refocusing the Issue Content Type Journal Article Pages 351-364 DOI 10.1007/s10730-009-9113-x Authors Natasha T. Morton, The University of Western Ontario Ontario Canada N6A 5B9 Kenneth W. Kirkwood, Arthur and Sonia Labatt Health Sciences Building London Ontario Canada N6A 5B9 Journal HEC Forum Online ISSN 1572-8498 Print ISSN 0956-2737 Journal Volume Volume 21 Journal Issue Volume 21, Number 4.

This article argues that Kant's essay on enlightenment responds to Moses Mendelssohn's defense of the freedom of conscience in Jerusalem. While Mendelssohn holds that the freedom of conscience as an inalienable right, Kant argues that the use of one's reason may be constrained by oaths. Kant calls such a constrained use of reason the private use of reason. While he also defends the unconditional freedom of the public use of reason, Kant believes that one makes oneself a part of the (...) machinery of the church or state by swearing an oath to and assuming a position within those institutions. -/- The appendix to this article includes a translation of Mendelssohn's comments on Kant's enlightenment essay, "Public and Private Use of Reason.". (shrink)

Bioethicists commenting on conscientious objection and abortion should consider the empirical data on abortion providers. Abortion providers do not fall neatly into groups of providers and objectors, and ambivalence is a key theme in their experience. Practical details of abortion services further upset the dichotomy. These empirical facts are important because they demonstrate that the way the issue is described in analytical bioethics does not reflect reality. Addressing conscientious objection as a barrier to patient access requires engaging with those who (...) provide the service and those who are able to but do not. The experiences of doctors facing these decisions potentially challenge and expand our understanding of the issue as an ethical concern. (shrink)

: The standard bioethics account is that respecting patient autonomy means ensuring patients make their own decisions. In fact, respecting patient autonomy often has more to do with the overall shape and meaning of patients' health care regimes, and sometimes, at least, patients will very reasonably defer to medical authority.

The standard bioethics account is that respecting patient autonomy means ensuring that patients make their own decisions, and that requires that they give informed consent. In fact, respecting autonomy often has more to do with the overall shape and meaning of their health care regimes. Ideally, patients will sometimes take control of their health care but sometimes defer to medical authority. The physician's task is, in part, to inculcate patients into the appropriate good health care regimes.

This article critically evaluates the conception of conscience underlying the debate about the proper place and role of conscience in the clinical encounter. It suggests that recovering a conception of conscience rooted in the Catholic moral tradition could offer resources for moving the debate past an unproductive assertion of conflicting rights, namely, physicians’ rights to conscience versus patients’ rights to socially and legally sanctioned medical interventions. It proposes that conscience is a necessary component of the moral life in general and (...) a necessary resource for maintaining a coherent sense of moral agency. It demonstrates that an earlier and intellectually richer conception of conscience, in contrast with common contemporary formulations, makes the judgments of conscience accountable to reason, open to critique, and protected from becoming a bastion for bigotry, idiosyncrasy, and personal bias. (shrink)

Abstract:In this paper I explore the topic of moral compromise in institutional settings and highlight how moral compromise may affirm, rather than undermine, personal integrity. Central to this relationship between moral compromise and integrity is a view of the self that is responsive to multiple commitments and grounded in an ethic of responsibility. I elaborate a number of virtues that are related to this notion of the self and highlight how these virtues may support the development of individuals who are (...) responsive and reasonable in moral discourse and discerning in establishing moral limits on compromise. I look at how moral regret is closely connected to moral compromise and emphasize its significance for reinforcing personal integrity. The paper closes with a discussion of the relevance of these topics to the field of business ethics. (shrink)

Book reviewed in this article: Principles of Biomedical Ethics. By Tom L. Beauchamp and James F. Childress.

In recent years, virtue theories have enjoyed a renaissance of interest among general and medical ethicists. This book offers a virtue-based ethic for medicine, the health professions, and health care. Beginning with a historical account of the concept of virtue, the authors construct a theory of the place of the virtues in medical practice. Their theory is grounded in the nature and ends of medicine as a special kind of human activity. The concepts of virtue, the virtues, and the virtuous (...) physician are examined along with the place of the virtues of trust, compassion, prudence, justice, courage, temperance, and effacement of self-interest in medicine. The authors discuss the relationship between and among principles, rules, virtues, and the philosophy of medicine. They also address the difference virtue-based ethics makes in confronting such practical problems as care of the poor, research with human subjects, and the conduct of the healing relationship. This book woith the author's previous volumes, A Philosophical Basis of Medical Practice and For the Patient's Good, are part of their continuing project of developing a coherent moral philosophy of medicine. (shrink)

Historically associated with military service, conscientious objection has become a significant phenomenon in health care. Mark Wicclair offers a comprehensive ethical analysis of conscientious objection in three representative health care professions: medicine, nursing and pharmacy. He critically examines two extreme positions: the 'incompatibility thesis', that it is contrary to the professional obligations of practitioners to refuse provision of any service within the scope of their professional competence; and 'conscience absolutism', that they should be exempted from performing any action contrary to (...) their conscience. He argues for a compromise approach that accommodates conscience-based refusals within the limits of specified ethical constraints. He also explores conscientious objection by students in each of the three professions, discusses conscience protection legislation and conscience-based refusals by pharmacies and hospitals, and analyzes several cases. His book is a valuable resource for scholars, professionals, trainees, students, and anyone interested in this increasingly important aspect of health care. (shrink)

The sort of ethical theory derived from Aristotle, variously described as virtue ethics, virtue-based ethics, or neo-Aristotelianism, is becoming better known, and is now quite widely recognized as at least a possible rival to deontological and utilitarian theories. With recognition has come criticism, of varying quality. In this article I shall discuss nine separate criticisms that I have frequently encountered, most of which seem to me to betray an inadequate grasp either of the structure of virtue theory or of what (...) would be involved in thinking about a real moral issue in its terms. In the first half I aim particularly to secure an understanding that will reveal that many of these criticisms are simply misplaced, and to articulate what I take to be the major criticism of virtue theory. I reject this criticism, but do not claim that it is necessarily misplaced. In the second half I aim to deepen that understanding and highlight the issues raised by the criticisms by illustrating what the theory looks like when it is applied to a particular issue, in this case, abortion. (shrink)

The sort of ethical theory derived from Aristotle, variously described as virtue ethics, virtue-based ethics, or neo-Aristotelianism, is becoming better known, and is now quite widely recognized as at least a possible rival to deontological and utilitarian theories. With recognition has come criticism, of varying quality. In this article I shall discuss nine separate criticisms that I have frequently encountered, most of which seem to me to betray an inadequate grasp either of the structure of virtue theory or of what (...) would be involved in thinking about a real moral issue in its terms. In the first half I aim particularly to secure an understanding that will reveal that many of these criticisms are simply misplaced, and to articulate what I take to be the major criticism of virtue theory. I reject this criticism, but do not claim that it is necessarily misplaced. In the second half I aim to deepen that understanding and highlight the issues raised by the criticisms by illustrating what the theory looks like when it is applied to a particular issue, in this case, abortion. (shrink)

The Jubilee Centre’s new report, Virtuous Medical Practice, examines the place of character and values in the medical profession in Britain today. Its findings are drawn from a UK-focused multi-methods study of 549 doctors and aspiring doctors at three career stages, first and final year students and experienced doctors.