Over the course of its first seven editions, Principles of Biomedical Ethics has proved to be, globally, the most widely used, authored work in biomedical ethics. It is unique in being a book in bioethics used in numerous disciplines for purposes of instruction in bioethics. Its framework of moral principles is authoritative for many professional associations and biomedical institutions-for instruction in both clinical ethics and research ethics. It has been widely used in several disciplines for purposes of teaching in the (...) classroom, during conferences, etc. (shrink)

In this critique, Martha Nussbaum argues that our dominant theories of development have given us policies that ignore our most basic human needs for dignity and self-respect.

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

This paper compares and contrasts three different substantive principles of justice for making health care priority-setting or “rationing” decisions: need principles, maximising principles and egalitarian principles. The principles are compared by tracing out their implications for a hypothetical rationing decision involving four identified patients. This decision has been the subject of an empirical study of public opinion based on small-group discussions, which found that the public seem to support a pluralistic combination of all three kinds of rationing principle. In conclusion, (...) it is suggested that there is room for further work by philosophers and others on the development of a coherent and pluralistic theory of health care rationing which accords with public opinions. (shrink)

In his excellent essay, ‘Nudges in a post-truth world’, Neil Levy argues that ‘nudges to reason’, or nudges which aim to make us more receptive to evidence, are morally permissible. A strong argument against the moral permissibility of nudging is that nudges fail to respect the autonomy of the individuals affected by them. Levy argues that nudges to reason do respect individual autonomy, such that the standard autonomy objection fails against nudges to reason. In this paper, I argue that Levy (...) fails to show that nudges to reason respect individual autonomy. (shrink)

The shift away from paternalistic decision-making and toward patient-centered, shared decision-making has stemmed from the recognition that in order to practice medicine ethically, health care professionals must take seriously the values and preferences of their patients. At the same time, there is growing recognition that minor and seemingly irrelevant features of how choices are presented can substantially influence the decisions people make. Behavioral economists have identified striking ways in which trivial differences in the presentation of options can powerfully and predictably (...) affect people's choices. Choice-affecting features of the decision environment that do not restrict the range of choices or significantly alter the incentives have come to be known as “nudges.” Although some have criticized conscious efforts to influence choice, we believe that clinical nudges may often be morally justified. The most straightforward justification for nudge interventions is that they help people bypass their cognitive limitations—for example, the tendency to choose the first option presented even when that option is not the best for them—thereby allowing people to make choices that best align with their rational preferences or deeply held values. However, we argue that this justification is problematic. We argue that, if physicians wish to use nudges to shape their patients’ choices, the justification for doing so must appeal to an ethical and professional standard, not to patients’ preferences. We demonstrate how a standard with which clinicians and bioethicists already are quite familiar—the best-interest standard—offers a robust justification for the use of nudges. (shrink)

Changes in modern societies originate the perception that ethical behaviour is essential in organization’s practices especially in the way they deal with aspects such as human rights. These issues are usually under the umbrella of the concept of social responsibility. Recently the Report of the International Bioethics Committee of UNESCO on Social Responsibility and Health has addressed this concept of social responsibility in the context of health care delivery suggesting a new paradigm in hospital governance. The objective of this paper (...) is to address the issue of corporate social responsibility in health care, namely in the hospital setting, emphasising the special governance arrangements of such complex organisations and to evaluate if new models of hospital management (entrepreneurism) will need robust mechanisms of corporate governance to fulfil its social responsiveness. The scope of this responsible behaviour requires hospitals to fulfil its social and market objectives, in accordance to the law and general ethical standards. Social responsibility includes aspects like abstention of harm to the environment or the protection of the interests of all the stakeholders enrolled in the deliverance of health care. In conclusion, adequate corporate governance and corporate strategy are the gold standard of social responsibility. In a competitive market hospital governance will be optimised if the organization culture is reframed to meet stakeholders’ demands for unequivocal assurances on ethical behaviour. Health care organizations should abide to this new governance approach that is to create organisation value through performance, conformance and responsibility. (shrink)

As value chains become longer with increases in outsourcing and subcontracting, the challenges of fixing responsibility become more difficult. Using concepts from the literature on social networks, this paper considers issues of diffusion of responsibility and plausible deniability in such relationships. Specifically, this paper isolates three sources of denial of – or defense against – attributions of responsibility: connection, control and knowledge. It goes on to consider the effects on network density and actor centrality as third parties (tertius illuminans) alter (...) the structure of these networks. Finally, preliminary conclusions are considered including suggestions for addressing these new challenges as well as the potential for conceptual cross-fertilization between network analysis and organizationalethics. (shrink)

When information is transformed from what has traditionally been a paper-based format into digitized elements with meaning associated to them, new and intriguing discussions begin surrounding proper and improper uses of this codified and easily transmittable information. As these discussions continue, some health care providers, insurers, laboratories, pharmacies, and other healthcare stakeholders are creating and retroactively digitizing our medical information with the unambiguous endorsement of the federal government.Some argue that these enormous databases of medical information offer improved access to timely (...) information, evidence-based treatments, and complete records from which to provide care. To the extent that these claims are true, it would seem that this is a valuable asset that offers immeasurable benefit to all. Others believe this digitization to be an egregious invasion of privacy. In this article, I investigate the broad research questions of whether the public good aspect of capturing private health information outweighs individual interests and whether it is ethical to mandate participation in health information exchanges by all individuals who use the U.S. health system. (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)

Some philosophers have argued that during the process of obtaining informed consent, physicians should try to nudge their patients towards consenting to the option the physician believes best, where a nudge is any influence that is expected to predictably alter a person’s behaviour without restricting her options. Some proponents of nudging even argue that it is a necessary and unavoidable part of securing informed consent. Here I argue that nudging is incompatible with obtaining informed consent. I assume informed consent requires (...) that a physician tells her patient the truth about her options and argue that nudging is incompatible with truth-telling. Instead, nudging satisfies Harry Frankfurt’s account of bullshit. (shrink)

Suppose a meeting had been called among chief medical officers, chief administrative officers, and other leaders from a range of health-related institutions in this country. The question posed for this meeting was simple but unusual: Arethestructuresofourorganizations,systems,andinstitutionsethical? Though it was a question reminiscent for a few of the focus some time before on whether the conduct of individuals in their organization was ethical, this question seemed more demanding. Is it reasonable to consider structures or arrangements as ethical or not; or in (...) other words, is ethics an applicable attribute of organizations? And if it is reasonable to speak of an ethics of organizations, by what method might one discern any kind of an answer? And what of the informal connections that link different organizations … how can they be evaluated? (shrink)

Until recently, business issues in healthcare organizations were relatively insulated from clinical issues, for several reasons. The hospital at earlier stages of its development operated on a combination of charitable and equitable premises, allowing for providing care to be separated from financial support. Physicians, who were primarily responsible for clinical care, constituted an independent power nexus within the hospital and were governed by their own professional codes of ethics. In exchange for a great deal of control over their conditions of (...) practice, they took almost complete responsibility for patient care. Thus clinical and professional ethics could to some extent be compartmentalized from the business issues—a much easier feat when, as in much of the last few decades, virtually all care was reimbursed from some source or other. In addition, many HCOs were not categorized or treated as businesses, although of course they were presumed to be governed by the same expectation for good management as any other organization. (shrink)

In this editorial essay I explore the possibilities of ‘improvement scholarship’ in order to set the scene for the theme of, and the other papers in, this issue. I contrast a narrow conception of quality improvement research with a much broader and more inclusive conception, arguing that we should greatly extend the existing dialogue between ‘problem-solving’ and ‘critical’ currents in improvement research. I have in mind the potential for building a much larger conversation between those people in ‘improvement science’ who (...) are expressly concerned with tackling the problems facing healthcare and the wider group of colleagues who are engaged in health-related scholarship but who do not see themselves as particularly interested in quality improvement, indeed who may be critical of the language or concerns of QI. As one contribution to that conversation I suggest that that the increasing emphasis on theory and rigour in improvement research should include more focus on normative theory and rigour. The remaining papers in the issue are introduced including the various ways in which they handle the ‘implicit normativity’ of QI research and practice, and the linked theme of combining relatively ‘tidy’ and potentially ‘unruly’ forms of knowledge. (shrink)

In this issue of the Hastings Center Report, Moti Gorin, Steven Joffe, Neal Dickert, and Scott Halpern offer a comprehensive defense of the use of nudging techniques in the clinical context, with the aim of promoting the best interests of patients. Their argument is built on three important claims: Nudging is ubiquitous and inescapable in clinical choice situations, and there is no neutral way of informing patients about their treatment choices; many patients do not have authentic preferences concerning their treatment (...) choices, and those that do can easily resist nudging; and, finally, since many people lack authentic preferences and those that do can still act on their preferences, nudging in the patients’ best interest is justified. I agree with the authors that if these three claims stand up to scrutiny, then they will provide a justification for many types of clinical nudging. I am, however, skeptical as to whether the claims can be sustained, despite the valiant efforts of Gorin and colleagues. (shrink)