People who work and live in a certain moral practice usually possess a specific form of moral wisdom. If we manage to incorporate their moral intuitions in ethical reasoning, we can arrive at judgements and theories that grasp a moral experience that generally cannot be found outside the said practice. To achieve this goal, we need a legitimate way to balance moral intuitions, ethical principles and general theories. In the present contribution, we describe a version of the model of Reflective (...) Equilibrium, which we call the Normative-Empirical Reflective Equilibrium . RE provides a framework for ethical thinking that includes both moral experience and normative theory.After an outline of the model, we focus on the role of empirical research and illustrate how empirical data on moral intuitions can add to the comprehensiveness of the set of moral beliefs in NE-RE. Subsequently, we describe how coherence among the elements of an NE-RE can be understood and measured. Finally, we address an important question for any method of moral reasoning: what is the status of the outcome of the reasoning process? This is a matter of justification. We argue for a so-called good reasoning-justified outcome strategy in NE-RE. This strategy is built on a reasoning process in which the reason-giving force of each element is tested and weighed. The thinker has to work towards a coherent view in which only the elements with sufficient justificatory power are retained. If the thinker decides that the elements fit together into a coherent view, a reflective equilibrium is reached. NE-RE is an attempt to describe a model for moral reasoning that can profit from the moral wisdom present among experienced agents through the use of empirical research. (shrink)

In discussions about the legalisation of active, voluntary euthanasia it is sometimes claimed that what should happen in a liberal society is that the two sides in the debate “agree to disagree”. This paper explores what is entailed by agreeing to disagree and shows that this is considerably more complicated than what is usually believed to be the case. Agreeing to disagree is philosophically problematic and will often lead to an unstable compromise.

People who work and live in a certain moral practice usually possess a specific form of moral wisdom. If we manage to incorporate their moral intuitions in ethical reasoning, we can arrive at judgements and theories that grasp a moral experience that generally cannot be found outside the said practice. To achieve this goal, we need a legitimate way to balance moral intuitions, ethical principles and general theories. In the present contribution, we describe a version of the model of Reflective (...) Equilibrium, which we call the Normative-Empirical Reflective Equilibrium . RE provides a framework for ethical thinking that includes both moral experience and normative theory.After an outline of the model, we focus on the role of empirical research and illustrate how empirical data on moral intuitions can add to the comprehensiveness of the set of moral beliefs in NE-RE. Subsequently, we describe how coherence among the elements of an NE-RE can be understood and measured. Finally, we address an important question for any method of moral reasoning: what is the status of the outcome of the reasoning process? This is a matter of justification. We argue for a so-called good reasoning-justified outcome strategy in NE-RE. This strategy is built on a reasoning process in which the reason-giving force of each element is tested and weighed. The thinker has to work towards a coherent view in which only the elements with sufficient justificatory power are retained. If the thinker decides that the elements fit together into a coherent view, a reflective equilibrium is reached. NE-RE is an attempt to describe a model for moral reasoning that can profit from the moral wisdom present among experienced agents through the use of empirical research. (shrink)

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

Since it appeared in 1971, John Rawls's A Theory of Justice has become a classic. The author has now revised the original edition to clear up a number of difficulties he and others have found in the original book. Rawls aims to express an essential part of the common core of the democratic tradition--justice as fairness--and to provide an alternative to utilitarianism, which had dominated the Anglo-Saxon tradition of political thought since the nineteenth century. Rawls substitutes the ideal of the (...) social contract as a more satisfactory account of the basic rights and liberties of citizens as free and equal persons. "Each person," writes Rawls, "possesses an inviolability founded on justice that even the welfare of society as a whole cannot override." Advancing the ideas of Rousseau, Kant, Emerson, and Lincoln, Rawls's theory is as powerful today as it was when first published. (shrink)

Though the revised edition of A Theory of Justice, published in 1999, is the definitive statement of Rawls's view, so much of the extensive literature on Rawls's theory refers to the first edition. This reissue makes the first edition once again available for scholars and serious students of Rawls's work.

We create a database of company codes of ethics from firms listed on the Standard & Poor's 500 Index and, separately, a sample of small firms. The SEC believes that "ethics codes do, and should, vary from company to company." Using textual analysis techniques, we measure the extent of commonality across the documents. We find substantial levels of common sentences used by the firms, including a few cases where the codes of ethics are essentially identical. We consider these results in (...) the context of legal statements versus value statements. While legal writing often mandates duplication, we argue that value-based statements should be held to a higher standard of originality. Our evidence is consistent with isomorphic pressures on smaller firms to conform. (shrink)

I address three topics. First, I argue that the issue of corporate moral responsibility is an important one for business ethics.Second, I examine a core argument for the claim that the corporate organization is a separate moral agent and show it is based on anunnoticed but elementary mistake deriving from the fallacy of division. Third, I examine the assumptions collectivists make about whatit means to say that organizations act and that they act intentionally and show that these assumptions are mistaken (...) in their failure to understand the nature of intentional causality and of “as-if” intentionality. In exposing these mistakes I set out my own view in the form oftwo theses, the first of which states that individual members of an organization are always causally responsible for any corporate act,and the second of which states that attributions of intentions to corporations are always either descriptive or prescriptive attributionsof “as if” intentionality. (shrink)

The field of bioethics is increasingly coming into contact with empirical research findings. In this article, we ask what role empirical research can play in the process of ethical clarification and decision-making. Ethical reflection almost always proceeds in three steps: the description of the moral question,the assessment of the moral question and the evaluation of the decision-making. Empirical research can contribute to each step of this process. In the description of the moral object, first of all, empirical research has a (...) role to play in the description of morally relevant facts. It plays a role in answering the “reality-revealing questions” (what, why,how, who, where and when), in assessing the consequences and in proposing alternative courses of action. Secondly, empirical research plays a role in assessing the moral question. It must be acknowledged that research possesses “the normative power of the factual,” which can also become normative by suppressing other norms. However, inductive normativity should always be balanced out by a deductive form of normativity. Thirdly, empirical research also has a role to play in evaluating the decision-making process. It can rule out certain moral choices by pointing out the occurrence of certain unexpected consequences or effects. It can also be useful, however, as a sociology of bioethics in which the discipline of bioethics itself becomes an object of research. (shrink)

Though the art of compromise, i.e. of settling differences by mutual concessions, is part of communal living on any level, we often think that there is something wrong in compromise, especially in cases where moral convictions are involved. A first reason for distrusting compromises on moral matters refers to the idea of integrity, understood in the basic sense of 'standing for something', especially standing for the values and causes that to some extent confer identity. The second reason points out the (...) objective nature of moral values, which seems to make them immune from negotiation and barter. If one sincerely holds some moral conviction to be true, than compromising on that belief must be a sign of serious confusion.In order to reach a better understanding of these two reasons, I analyse what is involved in personal integrity and how this relates to moral integrity. I argue that the search for moral integrity naturally brings us to the question of how one could accept moral compromises and still uphold the idea that moral values and principles have an objective authority over us. To address this question I will present a version of moral pluralism which tries to capture the enormous complexity of what should matter to us as moral persons, and which explains why value-rankings are often deeply indeterminate. The general position I defend in this paper is that compromises involving moral values and norms may be morally required and, therefore, be laudable. To sustain this position I will arrive at a view of ethical objectivity that allows the possibility to negotiate about the truth of moral beliefs. (shrink)

Should you wash your hands? -- Are workarounds ethical? -- Turfing, bending, and gaming -- Dirty hands and the semiclear conscience -- Problems of humanity -- Ethics without heroics : foreseeing moral problems in complex systems.

Compromise on moral matters attracts ambivalent reactions, since it seems at once laudable and deplorable. When a hotly-contested phenomenon like assisted dying is debated, all-or-nothing positions tend to be advanced, with little thought given to the desirability of, or prospects for, compromise. In response to recent articles by Søren Holm and Alex Mullock, in this article I argue that principled compromise can be encouraged even in relation to this phenomenon, provided that certain conditions are present . In order to qualify (...) as appropriately principled, the ensuing negotiations require disputants to observe three constraints: they should be suitably reflective, reliable and respectful in their dealings with one another. The product that will result from such a process will also need to split the difference between the warring parties. In assisted dying, I argue that a reduced offence of ‘compassionate killing’ can achieve this. I acknowledge, however, that splitting the difference can induce splitting headaches, as there remain certain questions to be answered. Hopefully, however, sufficient work is done here to defend attempts to occupy the middle ground, whether these relate to assisted dying specifically or to other disputed moral matters. (shrink)

Bioethics is not merely a theoretical discipline but a practice as well. Indeed, bioethics is a sort of moral trade. Bioethicists serve on ethics committees, give expert testimony to courts, provide guidance for healthcare policy, and receive payment for these services. The difficulty is that their role as experts able to guide clinical choice and public policy formation is brought into question by the diversity of moral understandings regarding central moral issues at the heart of the culture wars in healthcare. (...) The disconfirmation of the expert role of bioethicists by their apparent actual role as partisans of particular moral schools and perspectives could be set aside, were there an avenue to moral consensus, a door to a common moral vision to guide this new profession of moral experts. This brief article addresses the hunger for consensus in bioethics, its impossibility with respect to the controversial issues that mark the field, and the inclination nevertheless to deny this manifest diversity by appeals to a consensus that could allow bioethicists to function as ethics experts able substantively to guide clinical choices and public policy. (shrink)

The philosophy of medicine cum bioethics has become the socially recognized source for moral and epistemic direction in health-care decision-making. Over the last three decades, this field has been accepted politically as an authorized source of guidance for policy and law. The field's political actors have included the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, the Department of Health, Education, and Welfare, the President's Commission for the Study of Ethical Problems in Medicine and Biomedical (...) and Behavioral Research , the National Bioethics Advisory Commission, and the new Council on Bioethics; these groups and agencies have set forth rules on issues ranging from the role of humans in biomedical research to the production of human embryos for research, the definition of death, and the permissibility of human cloning. The members of the field are not just scholars and teachers in an academic realm directed to both theoretical and applied issues. They are, in addition, practitioners of a conceptual and moral trade that possesses a legal and political standing. This essay critically addresses the sudden emergence of bioethics as a societally recognized source of moral guidance, a source replete with authorized moral experts. Attention is directed to moral and conceptual assumptions that have led the philosophy of medicine, and especially bioethics, to acquire a quasi-juridical/political role in guiding clinical choices, framing health-care policy, and directing court holdings. (shrink)

This paper is predicated on the understanding that clinical encounters between clinicians and patients should be seen primarily as inter-relations among persons and, as such, are necessarily moral encounters. It aims to relocate the discussion to be had in challenging medical decision-making situations, including, for example, as the end of life comes into view, onto a more robust moral philosophical footing than is currently commonplace. In our contemporary era, those making moral decisions must be cognizant of the existence of perspectives (...) other than their own, and be attuned to the demands of inter-subjectivity. Applicable to clinical practice, we propose and justify a Habermasian approach as one useful means of achieving what can be described as dialogic consensus. The Habermasian approach builds around, first, his discourse theory of morality as universalizable to all and, second, communicative action as a cooperative search for truth. It is a concrete way to ground the discourse which must be held in complex medical decision-making situations, in its actual reality. Considerations about the theoretical underpinnings of the application of dialogic consensus to clinical practice, and potential difficulties, are explored. (shrink)

This work focuses upon decisions to withhold or withdraw life-supporting treatment from incompetent patients. It offers a critical examination of the latest developments with a view to developing a new framework for resolving disputes in the clinic that is not only theoretically robust but also practically relevant.

A traditional approach to teaching medical ethics aims to provide knowledge about ethics. This is in line with an epistemological view on ethics in which moral expertise is assumed to be located in theoretical knowledge and not in the moral experience of healthcare professionals. The aim of this paper is to present an alternative, contextual approach to teaching ethics, which is grounded in a pragmatic-hermeneutical and dialogical ethics. This approach is called moral case deliberation. Within moral case deliberation, healthcare professionals (...) bring in their actual moral questions during a structured dialogue. The ethicist facilitates the learning process by using various conversation methods in order to find answers to the case and to develop moral competencies. The case deliberations are not unique events, but are a structural part of the professional training on the work floor within healthcare institutions. This article presents the underlying theory on ethics and illustrates this approach with an example of a moral case deliberation project in a Dutch psychiatric hospital. The project was evaluated using the method of responsive evaluation. This method provided us with rich information about the implementation process and effects the research process itself also lent support to the process of implementation. (shrink)

Catholic healthcare institutions live amidst tension between three intersecting primary values, namely, a commitment of service to the poor and vulnerable, promoting the common good for all, and financially sustainability. Within this tension, the question sometimes arises as to whether it is ever justifiable, i.e., consistent with Catholic identity, to place limits on charity care. In this article we will argue that the health reform measures of the Affordable Care Act do not eliminate this tension but actually increase the urgency (...) of addressing it. Moreover, we will conclude that the question of limiting charity care in a manner that is consistent with the obligations of Catholic identity around serving the poor and vulnerable, promoting the common good, and remaining financially sustainable is not a question of if, but of how such limits are established. Such limits, however, cannot be established in light of one overriding moral consideration or principle, but must be established in light of a multitude of principles guiding us to a holistic understanding of the interrelatedness of the moral dimensions of Catholic identity. (shrink)

In this paper the moral responsibility of a Healthcare Organization (HCO) is conceived as an inextricable aspect of the identity of the HCO. We attempt to show that by exploring this relation a more profound insight in moral responsibility can be gained. Referring to Charles Taylor we explore the meaning of the concept of identity. It consists of three interdependent dimensions: a moral, a dialogical, and a narrative one. In section two we develop some additional arguments to apply his concept (...) of personal identity to organizations. The final section works out the relationship of three dimensions of identity to some actual issues in contemporary HCOs: the tension between care and justice, the importance of dialogues about the diversity of goods, and the relevance of becoming familiar with the life-story of the HCO. Identity of an HCO is established and developed in commitments to and identification with certain goods that are central for a HCO. However, many of these goods are interwoven with everyday practices and policies. Therefore, moral responsibility asks for articulation of goods that often stay implicit and should not be reduced to a merely procedural approach. However difficult this articulation may be, if it is not tried at all HCOs run the risk of drifting away from their very identity as healthcare institutions: to offer care to patients and to do this in accordance with demands of social justice. (shrink)

Matters of hospital management do not figure prominently on the medical ethics agenda. However, management decisions that have to be taken in the area of hospital care are in fact riddled with ethical questions and do have significant impact on patients, staff members, and the community being served. In this decision making process evidence based medicine plays an increasingly important role as a tool for rationalising as well as rationing health care resources. In this article, ethical issues of hospital management (...) and the role of EBM will be explored, with particular reference to disease management programs, diagnosis related groups, and clinical pathways as recent developments in the German health care system. (shrink)