In a recent article in this Journal, Shlomo Cohen and Haim Shapiro introduce the concept of “comparable placebo treatments” —placebo treatments with biological effects similar to the drugs they replace—and argue that doctors are not being deceptive when they prescribe or administer CPTs without revealing that they are placebos. We critique two of Cohen and Shapiro’s primary arguments. First, Cohen and Shapiro argue that offering undisclosed placebos is not lying to the patient, but rather is making a self-fulfilling prophecy—telling a (...) “lie” that, ideally, will become true. We argue that offering undisclosed placebos is not a “lie” but is a straightforward case of deceptively misleading the patient. Second, Cohen and Shapiro argue that offering undisclosed CPTs is not equivocation. We argue that it typically is equivocation or deception of another sort. If justifiable, undisclosed placebo use will have to be justified as a practice that is deceptive in most instances. (shrink)

Moral distress is one of the core topics of clinical ethics. Although there is a large and growing empirical literature on the psychological aspects of moral distress, scholars, and empirical investigators of moral distress have recently called for greater conceptual clarity. To meet this recognized need, we provide a philosophical taxonomy of the categories of what we call ethically significant moral distress: the judgment that one is not able, to differing degrees, to act on one’s moral knowledge about what one (...) ought to do. We begin by unpacking the philosophical components of Andrew Jameton’s original formulation from his landmark 1984 work and identify two key respects in which that formulation remains unclear: the origins of moral knowledge and impediments to acting on that moral knowledge. We then selectively review subsequent literature that shows that there is more than one concept of moral distress and that explores the origin of the values implicated in moral distress and impediments to acting on those values. This review sets the stage for identifying the elements of a philosophical taxonomy of ethically significant moral distress. The taxonomy uses these elements to create six categories of ethically significant moral distress: challenges to, threats to, and violations of professional integrity; and challenges to, threats to, and violations of individual integrity. We close with suggestions about how the proposed philosophical taxonomy of ethically significant moral distress sheds light on the concepts of moral residue and crescendo effect of moral distress and how the proposed taxonomy might usefully guide prevention of and future qualitative and quantitative empirical research on ethically significant moral distress. (shrink)

The fundamental claim that the practice of medicine is essentially a moral enterprise remains highly contentious, not least among the dominant traditional moral theories. The medical profession itself is today characterized by multicultural pluralism and moral relativism that have left the Hippocratic moral tradition largely in disarray. In this paper, I attempt to clarify the ambiguity about practicing medicine as a moral enterprise and echo Pellegrino’s call for a phenomenologically and teleologically derived philosophy of medicine. I proffer a realistic trifocal (...) matrix in which the virtuous moral agency and the teleologically derived moral imperative of the physician are comprehensively integrated with an action-guiding practical analytical framework for the resolution of ethical dilemmas in medicine. I argue that this trifocal perspective points us towards an authentic philosophy of medicine that is not only verifiable through Lonerganian self-appropriation, but also authentically objective through the possible moral self-transcendence of the good physician. (shrink)

In this paper, I argue that deceptive placebo use can be morally permissible, on the grounds that the deception involved in the prescription of deceptive placebos can differ in kind to the sorts of deception that undermine personal autonomy. In order to argue this, I shall first delineate two accounts of why deception is inimical to autonomy. On these accounts, deception is understood to be inimical to the deceived agent’s autonomy because it either involves subjugating the deceived agent’s will to (...) another’s authority or because it precludes the agent from acting effectively in pursuit of their ends. I shall argue that providing an agent with false beliefs is not inimical to their autonomy if they are only able to effectively pursue their autonomously chosen ends by virtue of holding those particular false beliefs. Finally, I show that deceptive placebo use need only involve this latter sort of deception. (shrink)

The moral authority for professional ethics in medicine customarily rests in some source external to medicine, i.e., a pre-existing philosophical system of ethics or some form of social construction, like consensus or dialogue. Rather, internal morality is grounded in the phenomena of medicine, i.e., in the nature of the clinical encounter between physician and patient. From this, a philosophy of medicine is derived which gives moral force to the duties, virtues and obligations of physicians qua physicians. Similarly, an ethic specific (...) to the other healing professions, law, teaching or ministry, can be derived from the specific ends to telos of each of these professions, which like medicine, are focused on a special type of human relationship. (shrink)

Virtue is the most perdurable concept in the history of ethics, which is understandable given the ineradicability of the moral agent in the events of the moral life. Historically, virtue enjoyed normative force as long as the philosophical anthropology and the metaphysics of the good that grounded virtue were viable. That grounding has eroded in both general and medical ethics. If virtue is to be restored to a normative status, its philosophical underpinnings must be reconstructed. Such reconstruction seems unlikely in (...) general ethics, where the possibility of agreement on the good for humans is remote. However, it is a realistic possibility in the professional ethics of the health professions where agreement on the telos of the healing relationship is more likely to arise. Nevertheless, virtue-based ethics must be related conceptually and normatively to other ethical theories in a comprehensive moral philosophy of the health professions. (shrink)

Bioethics has a founding story in which medical paternalism, the interference with the autonomy of patients for their own clinical benefit, was an accepted ethical norm in the history of Western medical ethics and was widespread in clinical practice until bioethics changed the ethical norms and practice of medicine. In this paper I show that the founding story of bioethics misreads major texts in the history of Western medical ethics. I also show that a major source for empirical claims about (...) the widespread practice of medical paternalism has been misread. I then show that that bioethics based on its founding story deprofessionalizes medical ethics. The result leaves the sick exposed to the predatory power of medical practitioners and healthcare organizations with only their autonomy-based rights to non-interference, expressed in contracts, to protect them. The sick are stripped of the protection afforded by a professional, fiduciary relationship of physicians to their patients. Bioethics based on its founding story reverts to the older model of a contractual relationship between the sick and medical practitioners not worthy of intellectual or moral trust (because such trust cannot be generated by what I call ‘deprofessionalizing bioethics’). On closer examination, bioethics based on its founding story, ironically, eliminates paternalism as a moral category in bioethics, thus causing bioethics to collapse on itself because it denies one of the necessary conditions for medical paternalism. Bioethics based on its founding story should be abandoned. (shrink)

Medical bribery seems to be a global problem from Eastern Europe and the Balkans to China, a diffuse phenomenon, starting with morally acceptable gratitude and ending with institutional bribery. I focus my attention on Romania and analyze similar cases in Eastern European and postcommunist countries. Medical bribery can be regarded as a particular form of human transaction, a kind of primitive contract that occurs when people do not trust institutions or other forms of social contract that are meant to guarantee (...) their rights and protect their interests. Concluding with strategies to fight medical bribery, I will underline better public policies for financing health and social care, and an ethic of trust that may help to restore trustworthiness of institutions and to rebuild interpersonal trust. This should be complemented by an educational program dedicated to understanding the negative consequences and mechanisms of corruption and the importance of ethical behavior. (shrink)

This paper demonstrates how the problematic kinds of epistemic power that physicians have can diminish the epistemic privilege that pregnant women have over their bodies and can put them in a state of epistemic powerlessness. This result, I argue, constitutes an epistemic injustice for many pregnant women. A reconsideration of how we understand and care for pregnant women and of the physician–patient relationship can provide us with a valuable context and starting point for helping to alleviate the knowledge/power problems that (...) are symptomatic of the current system and structure of medicine. I suggest that we can begin to confront this kind of injustice if medicine adopts a more phenomenological understanding of bodies and if physicians and patients—in this case, pregnant women—become what I call “epistemic peers.”. (shrink)

This response to Kevin WildesÕs article in the previous issue of the Kennedy Institute of Ethics Journal addresses several major points of disagreement between Pellegrino and Wildes regarding the nature and scope of a philosophy of medicine, in particular how it is derived and by what method of philosophical enquiry it is best pursued.

The best things in my Ufe have come to me by accident and this book results from one such accident: my having the opportunity, out of the blue, to go to work as H. Tristram Engelhardt, Jr. 's, research assistant at the Institute for the Medical Humanities in the University of Texas Medi cal Branch at Galveston, Texas, in 1974, on the recommendation of our teacher at the University of Texas at Austin, Irwin C. Lieb. During that summer Tris "lent" (...) me to Chester Bums, who has done important schol arly work over the years on the history of medical ethics. I was just finding out what bioethics was and Chester sent me to the rare book room of the Medical Branch Library to do some work on something called "medical deontology. " I discovered that this new field of bioethics had a history. This string of accidents continued, in 1975, when Warren Reich (who in 1979 made the excellent decisions to hire me to the faculty in bioethics at the Georgetown University School of Medicine and to persuade Andre Hellegers to appoint me to the Kennedy Institute of Ethics) took Tris Engelhardt's word for it that I could write on the history of modem medical ethics for Warren's major new project, the Encyclopedia of Bioethics. Warren then asked me to write on eighteenth-century British medical ethics. (shrink)