The clinical ethics literature is striking for the absence of an important genre of scholarship that is common to the literature of clinical medicine: systematic reviews. As a consequence, the field of clinical ethics lacks the internal, corrective effect of review articles that are designed to reduce potential bias. This article inaugurates a new section of the annual "Clinical Ethics" issue of the Journal of Medicine and Philosophy on systematic reviews. Using recently articulated standards for argument-based normative ethics, we provide (...) a systematic review of the literature on concealed medication for the management of psychiatric disorders. Four steps are completed: identify a focused question; conduct a literature search using key terms relevant to the focused question; assess the adequacy of the argument-based methods of the papers identified; and identify conclusions drawn in each paper and whether they apply to the focused question. We identified seven papers and provide an assessment of them. While none of the papers fully meet the standards of argument-based ethics, they did provide rationales for the use of concealed medications, with the important requirement such a practice be accountable in explicit organizational policy to prevent abuse of patients with mental illness or dementia. (shrink)

Despite the prevalence of the terms utilitarianism and utilitarian in the health care and health policy literature, anecdotal evidence suggests that authors are often not fully aware of the diversity of utilitarian theories, their principles, and implications. Further, it seems that authors often categorically reject utilitarianism under the assumption that it violates individual rights. The tendency of act utilitarianism to neglect individual rights is attenuated, however, by the diminishing marginal utility of wealth and the disutility of a protest by those (...) who are disadvantaged. In practice, act utilitarians tend to introduce moral rules and preserve traditional rules. At the same time, the tenability of rule utilitarianism is limited because it ultimately collapses into act utilitarianism or a deontological theory. Negative utilitarianism is a viable utilitarian variant only if we accept complete aversion to suffering, ie, if we disregard any forgone opportunities to increase pleasure. Finally, the adoption of preference utilitarianism requires us to accept the subjectivity of individual claims which may be perceived as unfair. (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.

Bioethics can be considered as a topic, an academic discipline, a field of study, an enterprise in persuasion. The historical specificity of the forms bioethics takes is significant, and raises questions about some of these approaches. Bioethics can also be considered as a governance practice, with distinctive institutions and structures. The forms this practice takes are also to a degree country specific, as the paper illustrates by drawing on the author’s UK experience. However, the UNESCO Universal Declaration on Bioethics can (...) provide a starting point for comparisons provided that this does not exclude sensitivity to the socio-political context. Bioethics governance practices are explained by various legitimating narratives. These include response to scandal, the need to restrain irresponsible science, the accommodation of pluralist views, and the resistance to the relativist idea that all opinions count equally in bioethics. Each approach raises interesting questions and shows that bioethics should be studied as a governance practice as a complement to other approaches. (shrink)

I agree with Scott A Anderson1 and Rosalind J McDougall2 that many prostitutes suffer significant harms, and that these harms must be taken seriously. Having a background in public outreach for sex workers, I share this concern wholeheartedly.In the article to which Anderson and McDougall respond,3 I ask why prostitutes are harmed: are prostitutes harmed because prostitution itself is harmful or because of contingent ways in which prostitutes are socially and legally treated? This is an important question, since if the (...) latter is the case, then the widespread moral and legal campaign against prostitution, rather than being a legitimate response to something harmful, is itself the source of much suffering and distress. In my article, I argue at length that it is indeed our social and legal treatment of prostitutes that is the dominant source of harm.Neither Anderson nor McDougall seems to take issue with my rebuttal of the nine most central arguments in favour of the view that prostitution itself is harmful. They do, however, raise a number of more general issues, and I shall now address these.A worry raised by Anderson is that in defending the view that prostitution itself is not harmful, I am ‘abstracting away from key facts about the context in which prostitution takes place’, and as such, I ‘fail to recognize how contextual, historical and social’ prostitution really is. I think this is a good objection — so good, in fact, that I raise and discuss it in the article. I formulate the objection as follows: "[The objection] states that my argument is utopian: that prostitution is a complex practice deeply entrenched in a long line of other social and psychological issues, such as gender inequality, poverty, power hierarchies and exploitation, and that … ". (shrink)

Systematic reviews, which were developed to improve policy-making and clinical decision-making, answer an empirical question based on a minimally biased appraisal of all the relevant empirical studies. A model is presented here for writing systematic reviews of argument-based literature: literature that uses arguments to address conceptual questions, such as whether abortion is morally permissible or whether research participants should be legally entitled to compensation for sustaining research-related injury. Such reviews aim to improve ethically relevant decisions in healthcare, research or policy. (...) They are better tools than informal reviews or samples of literature with respect to the identification of the reasons relevant to a conceptual question, and they enable the setting of agendas for conceptual and empirical research necessary for sound policy-making. This model comprises prescriptions for writing the systematic review's review question and eligibility criteria, the identification of the relevant literature, the type of data to extract on reasons and publications, and the derivation and presentation of results. This paper explains how to adapt the model to the review question, literature reviewed and intended readers, who may be decision-makers or academics. Obstacles to the model's application are described and addressed, and limitations of the model are identified. (shrink)

The recent interest in systematic review methods in bioethics has highlighted the need for greater transparency in all literature review processes undertaken in bioethics projects. In this article, I articulate features of a good bioethics literature review that does not aim to be systematic, but rather to capture and analyse the key ideas relevant to a research question. I call this a critical interpretive literature review. I begin by sketching and comparing three different types of literature review conducted in bioethics (...) scholarship. Then, drawing on Dixon-Wood's concept of critical interpretive synthesis, I put forward six features of a good critical interpretive literature review in bioethics: answering a research question, capturing the key ideas relevant to the research question, analysing the literature as a whole, generating theory, not excluding papers based on rigid quality assessment criteria, and reporting the search strategy. (shrink)

There are few participants in academic or policy debates over prostitution who would disagree that steps should be taken to improve conditions for those working in prostitution; so Moen1 is in good and plentiful company with respect to his recommendations.I will focus here on the analysis leading up to his conclusions, and with whether it helps us understand why prostitution is so commonly harmful and what it would take to mitigate those harms.i On these matters I am dubious. The question (...) of whether or not prostitution is harmful would seem, manifestly, to be an empirical question, rather than a philosophical issue. I take it that Moen's aim is to clarify the evaluative task, and then to evaluate the arguments that can be made to show prostitution is harmful—tasks which philosophers can responsibly engage in. But I would suggest that Moen's approach to this particular subject oversimplifies it by abstracting away from key facts about the context in which prostitution takes place, and thus that it does not offer as strong a case for normalising prostitution as he hopes.The basic thesis of Moen's essay is that if casual sex is harmless , then the sale of casual sexual services for money is also harmless, or at …. (shrink)

While the bioethics literature demonstrates that the field has spent substantial time and thought over the last four decades on the goals, methods, and desired outcomes for service and training in bioethics, there has been less progress defining the nature and goals of bioethics research and scholarship. This gap makes it difficult both to describe the breadth and depth of these areas of bioethics and, importantly, to gauge their success. However, the gap also presents us with an opportunity to define (...) this scope of work for ourselves and to help shape the broader conversation about the impact of academic research. Because of growing constraints on academic funding, researchers and scholars in many fields are being asked to demonstrate and also forecast the value and impact of their work. To do that, and also to satisfy ourselves that our work has meaningful effect, we must understand how our work can motivate change and how that change can be meaningfully measured. In a field as diverse as bioethics, the pathways to and metrics of change will likewise be diverse. It is therefore critical that any assessment of the impact of bioethics research and scholarship be informed by an understanding of the nature of the work, its goals, and how those goals can and ought to be furthered. In this paper, we propose a conceptual model that connects individual bioethics projects to the broader goals of scholarship, describing the translation of research and scholarly output into changes in thinking, practice, and policy. One of the key implications of the model is that impact in bioethics is generally the result of a collection of projects rather than of any single piece of research or scholarship. Our goal is to lay the groundwork for a thoroughgoing conversation about bioethics research and scholarship that will advance and shape the important conversation about their impact. (shrink)

Ethical notions such as good and bad, are often treated as though they were ?symmetric? in the sense of having the same moral ?weight?, one in a positive the other in a negative sense. I argue that they are in fact ?asymmetric? and that the negative members of such pairs of notions are more fundamental and definite, logically speaking, and operationally more important than the positive members. Detailed arguments are given to show this for some non?moral notions, such as life (...) and death, health and illness; some semi?moral notions such as pleasure and pain; and finally for the moral notions of happiness, benevolence, right, and good and their negative counterparts. One of the intentions of the article is to show that a systematic view of such asymmetries may have consequences for one's view of the proper or desirable structure of a general theory of ethics: norms stating prohibitions and norms stating permissions will be seen to be, in a sense defined in the text, more fundamental and important than norms stating ('positive') obligations. (shrink)

Although ethics consultation is offered as a clinical service in most hospitals in the United States, few valid and practical tools are available to evaluate, ensure, and improve ethics consultation quality. The quality of ethics consultation is important because poor quality ethics consultation can result in ethically inappropriate outcomes for patients, other stakeholders, or the health care system. To promote accountability for the quality of ethics consultation, we developed the Ethics Consultation Quality Assessment Tool. ECQAT enables raters to assess the (...) quality of ethics consultations based on the written record. Through rigorous development and preliminary testing, we identified key elements of a quality ethics consultation, established scoring criteria, developed training guidelines, and designed a holistic assessment process. This article describes the development of the ECQAT,.. (shrink)

A personal reflection upon a career in medical ethics leads to four conclusions on what makes for 'good medical ethics'. Good medical ethics is practical in approach, philosophically well grounded, cross disciplinary, and while it might not be a necessary feature, the experience of the author suggests that it is the work of 'good people'.

In this short critical analysis, the author examines the recent argument by Moen in his article ‘Is Prostitution Harmful?' In highlighting why prostitution does not cause harm to either member involved in the act, Moen argues that prostitution is not an ethical concern. However, while Moen is able to clearly challenge contemporary objections to prostitution, the author of this review will suggest that Moen's argument is itself incomplete as it does not address essential key ontological issues. This critical analysis will (...) briefly suggest why this omission weakens Moen's argument. Finally, it will conclude with examining why prostitution differs substantially from other professions through the type of harm that it causes to the moral agents involved. (shrink)

Moen targets a view about the intrinsic harmfulness of prostitution that he sees as widespread in healthcare, academia and public policy.1 He argues that the exchange of sex for money is not intrinsically harmful by systematically rejecting various possible proposed harms. He further suggests that it is the social context of discriminating laws and stigma that accounts for the harms experienced by prostitutes, rather than any intrinsic feature of exchanging sex for money.One striking aspect of his argument is the particular (...) way in which he characterises the common view about the harmfulness of prostitution. Consider the following two possible versions of the claim that prostitution is harmful: "The intrinsic claim: The exchange of sex for money is intrinsically harmful to the seller." "The contingent claim: Prostitutes are currently likely to experience significant harm."The intrinsic claim is …. (shrink)

This paper identifies four major forms of scholarship in bioethics: empirical research, the articulation of mid-level principles of bioethics, the relating of these principles to fundamental moral theories, and discussions of the bioethical implications of legal principles and health delivery policies. It develops a reflective equilibrium approach to the relation between these four forms of scholarship. It then presents, in light of this approach, criteria for quality research in each of these forms of scholarship in bioethics. Keywords: quality of scholarship, (...) reflective equilibria in bioethics, research in bioethics CiteULike Connotea Del.icio.us What's this? (shrink)

"Ethics and Experience" presents a wide-ranging and thought-provoking introduction to the question famously posed by Socrates: How is life to be lived? 'An excellent primer for any student taking a course on moral philosophy, the book introduces ethics as a single and broadly unified field of inquiry in which we apply reason to try and solve Socrates' question. "Ethics and Experience "examines the major forms of ethical subjectivism and objectivism - including expressivism, error theory', naturalism, and intuitionism. The book lays (...) out the detail of the most significant contemporary moral theories - including utilitarianism, virtue ethics, Kantianism, and contractarianism - and reconsiders these theories in the light of two questions that should perhaps be asked more often: Is moral theory, with its tendency to regiment ethical thought and experience, really the best way for us to apply reason to deciding how to live? And, might it not be more truly reasonable to look for less system and more insight? (shrink)

This paper discusses the character of medical ethics and suggests that there are significant gaps that warrant greater attention. It describes ways in which the content and form of medical ethics may exclude or marginalise perspectives and contributions, thereby reducing its influence and its potential impact on, and value to, patients, students, carers and society. To consider what it is ‘to do good medical ethics’ suggests an active approach that seeks out, and learns from, contributions beyond the traditional boundaries of (...) scholarship. (shrink)

This month's issue presents arguments on three longstanding ethical issues: prostitution, euthanasia and organ donation. It also addresses three issues perhaps more directly linked to daily practice across clinical care and research: resource allocation, consent, and, in an interesting pair of papers, how a clinician's own experiences might affect their ethical judgement and therefore clinical care.In a provocative article, Ole Martin Moen argues that our increasing acceptance of casual sex, that is, sexual encounters which do not involve an emotional connection, (...) render our assumption that prostitution is always harmful out of date. If one form of impersonal encounter is acceptable, then why not another? Naturally, prostitution involves some degree of risk of harm. However, he argues that many occupations we do accept are likewise risky, or are also subject to similar objections to prostitution. He allows there is one remaining harm, which is genuine today, but which is open to change: the legal and social stigma, which we impose on prostitution due to our mistaken beliefs .Our two invited commentators, Anderson and McDougall focus on the empirical evidence of harm. When a new drug is developed, a plausible theory as to its effects, mechanism and safety is required. We might test that in a computer model. But until it is tested in real life, we cannot know its real benefits or harms. The same might be true of ethical arguments. As McDougall says: "Moen presents a compelling argument that the exchange of sex for money need not be intrinsically harmful to the seller, but for the individuals actually involved in prostitution, does this conclusion really matter?"The reader might ask why a journal of medical ethics is publishing an article on prostitution. There are clearly potential and …. (shrink)

The criteria for determining what it is to do good medical ethics are the quality of ethical analysis and ethical justifications for decisions and actions. Justifications for decisions and actions rely on ethical principles, be they the ‘famous four’ or subsidiary ethical principles relevant to specific contexts. Examples from clinical ethics, research ethics and public health ethics reveal that even when not stated explicitly, principles are involved in ethical justifications. Principles may come into conflict, however, and the resolution of an (...) ethical dilemma requires providing good reasons for preferring one principle over another. (shrink)

How did bioethics manage to grow, flourish and ultimately do so well from a very unpromising birth in the 1970s? Many explanations have been advanced. Some ascribe the field9s growth to a puzzling, voluntary abnegation of moral authority by medicine to non-physicians. Some think bioethics survived by selling out to the biomedical establishment—public and private. This transaction involved bestowing moral approbation on all manner of biomedicine9s doings for a seat at a well-stocked funding table. Some see a sort of clever (...) intellectual bamboozlement at work wherein bioethicists pitched a moral elixir of objective expertise that the morally needy but unsophisticated in medicine and the biological sciences were eager to swallow. While each of these reasons has its defenders, I think the main reason that bioethics did well was that it did good. By using the media to move into the public arena, the field engaged the public imagination, provoked dialogue and debate, and contributed to policy changes that benefitted patients and healthcare providers. (shrink)