Stem cell research. Drug company influence. Abortion. Contraception. Long-term and end-of-life care. Human participants research. Informed consent. The list of ethical issues in science, medicine, and public health is long and continually growing. These complex issues pose a daunting task for professionals in the expanding field of bioethics. But what of the practice of bioethics itself? What issues do ethicists and bioethicists confront in their efforts to facilitate sound moral reasoning and judgment in a variety of venues? Are those immersed (...) in the field capable of making the right decisions? How and why do they face moral challenge -- and even compromise -- as ethicists? What values should guide them? In The Ethics of Bioethics, Lisa A. Eckenwiler and Felicia G. Cohn tackle these questions head on, bringing together notable medical ethicists and people outside the discipline to discuss common criticisms, the field's inherent tensions, and efforts to assign values and assess success. Through twenty-five lively essays examining the field's history and trends, shortcomings and strengths, and the political and policy interplay within the bioethical realm, this comprehensive book begins a much-needed critical and constructive discussion of the moral landscape of bioethics. (shrink)

For much of his adult life, Nietzsche wrote notes on philosophical subjects in small notebooks that he carried around with him. After his breakdown and subsequent death, his sister supervised the publication of some of these notes under the title The Will to Power, and that collection, which is textually inaccurate and substantively misleading, has dominated the English-speaking discussion of Nietzsche's later thought. The present volume offers, for the first time, accurate translations of a selection of writings from Nietzsche's late (...) notebooks, dating from his last productive years between 1885 and 1889. Many of them have never before been published in English. They are translated by Kate Sturge from reliable texts in the Colli-Montinari edition, and they are edited by Rüdiger Bittner, whose introduction places them in the context of Nietzsche's philosophy as a whole. (shrink)

Daybreak marks the arrival of Nietzsche's 'mature' philosophy and is indispensable for an understanding of his critique of morality and 'revaluation of all values'. This volume presents the distinguished translation by R. J. Hollingdale, with a new introduction that argues for a dramatic change in Nietzsche's views from Human, All Too Human to Daybreak, and shows how this change, in turn, presages the main themes of Nietzsche's later and better-known works such as On the Genealogy of Morality. The main themes (...) of Daybreak are located in their intellectual and philosophical contexts: in Nietzsche's training as a classical philologist and his fascination with the Sophists and Thucydides; in the moral philosophies of Kant and Schopenhauer, which are the central foci of Nietzsche's critique of morality; and in the German Materialist movement of the 1850s and after, which shaped Nietzsche's conception of persons. The edition is completed by a chronology, notes and a guide to further reading. (shrink)

In this article, I review and expand upon arguments showing that Freedman's so-called "clinical equipoise" criterion cannot serve as an appropriate guide and justification for the moral legitimacy of carrying out randomized clinical trials. At the same time, I try to explain why this approach has been given so much credence despite compelling arguments against it, including the fact that Freedman's original discussion framed the issues in a misleading way, making certain things invisible: Clinical equipoise is conflated with community equipoise, (...) and several versions of each are also conflated. But a misleading impression is given that, rather than distinct criteria being arbitrarily conflated, a puzzle is solved and a number of features unified. Various issues are pushed under the rug, hiding flaws of the "clinical equipoise" approach and thus deceiving us into thinking that we have a solution when we do not. Particularly significant is the ignoring of the crucial distinction between the individual patient decision and the policy decision. (shrink)

Context: Although ethics consultation is commonplace in United States (U.S.) hospitals, descriptive data about this health service are lacking. Objective: To describe the prevalence, practitioners, and processes of ethics consultation in U.S. hospitals. Design: A 56-item phone or questionnaire survey of the "best informant" within each hospital. Participants: Random sample of 600 U.S. general hospitals, stratified by bed size. Results: The response rate was 87.4%. Ethics consultation services (ECSs) were found in 81% of all general hospitals in the U.S., and (...) in 100% of hospitals with more than 400 beds. The median number of consults performed by ECSs in the year prior to survey was 3. Most individuals performing ethics consultation were physicians (34%), nurses (31%), social workers (11%), or chaplains (10%). Only 41% had formal supervised training in ethics consultation. Consultation practices varied widely both within and between ECSs. For example, 65% of ECSs always made recommendations, whereas 6% never did. These findings highlight a need to clarify standards for ethics consultation practices. (shrink)

Authority is an uneasy, political notion. Heard with modern ears, it calls forth images of oppression and power. In institutional settings, authority is everywhere present, and its use poses problems for the exercise both of individual autonomy and of responsibility. In medical ethics, the exercise of authority has been located on the side of the physician or the health care institution, and it has usually been opposed by appeal to patient autonomy and rights. So, it is not surprising, though still (...) ironic, that ethics consultation, which develops from this patient rights-dominated ethic, should itself bring forth questions of authority. Nonetheless, it does.Insofar as authority has been discussed in ethics consultations, it has been understandably approached from the broad perspective of legitimation and power, which are common themes in social and political treatments of authority. These treatments have dominated twentieth-century discussions of authority, which primarily view authority as legitimate power. (shrink)

The U.S.Supreme Court's 6-decision in Gonzales v. Oregon is the latest defeat for the Bush administration in its sustained attack on Oregon's physician-assisted suicide law. Both the majority opinion and the major dissent in Oregon provide an opportunity to assess the dangers inherent in allowing a political agenda that emphasizes the sanctity of life and minimizes professional ethical obligations to overshadow quality patient care at the end of life.

Bioethics, once a four-letter word in the private sector, is now an integral part of the decisionmaking process of biotechnology and pharmaceutical companies. And bioethicists, once confined to the classroom and limited to abstract, philosophical discussions about what is right and wrong in medicine and medical research, now play an important role in the practical implementation of ethical boundaries. Bioethicists increasingly are hired by biomedical companies as consultants to highlight and help resolve complex ethical issues that arise in the companies’ (...) normal business practices. Whether motivated by profit, reputation, or a genuine desire to act morally, these companies are willing to pay bioethicists substantial consultation fees for their “expert” opinions. This fairly recent phenomenon has caused some to be concerned about the potential for bioethicists to encounter conflicts of interests. Specifically, many critics of this new relationship between bioethicists and the private sector “are concerned about the appropriateness of ethicists who should have broader interests, such as concerns about social justice, serving clients whose primary interest is profit-maximizing.”. (shrink)

A significant amount of discussion in the bioethics community has been devoted to the question of whether individuals performing ethics consultations in healthcare institutions have any special expertise. In addition, articles in the lay press have questioned the “added value” that bioethicists bring to ethical dilemmas. Those at the forefront of the bioethics community have argued repeatedly that those doing ethics consults cannot simply be well-intentioned individuals, that some training in bioethics, group process, and facilitation is necessary to competently execute (...) a consult. As one bioethicist commented:if you approach any endeavor as an amateur activity, you will get, in the end, an amateurish version of the activity. Without a sufficient commitment of personnel, time, support, and financial resources, a healthcare organization will get the ‘ethics’ program … it set out to create: an inept, unskilled, inefficient, and highly risky ‘program’ in healthcare ethics and bioethics. (shrink)

Clinical ethical consultants are subject to an unavoidable conflict of interest. Their work requires that they be independent, but incentives attached to their role chip relentlessly at independence. This that they be independent, is a problem without any solution, but it can at least be ameliorated through careful management.

This book presents the latest data on -- and clinical, ethical, and medicolegal issues pertaining to -- sexual intimacy in the professional relationship. Contributors (including psychiatrists, psychologists, social workers, clergy, and attorneys) explore the issue of professional incest across the broad spectrum of the helping professions.

Clinical bioethics is big business. There are now hundreds of people who bioethics in community and university hospitals, nursing homes, rehabilitation and home care settings, and some who play the role of clinical ethics consultant to transplant teams, managed care companies, and genetic testing firms. Still, there is as much speculation about what clinically active bioethicists actually do as there was ten years ago. Various commentators have pondered the need for training standards, credentials, exams, and malpractice insurance for ethicists engaged (...) in clinical consultation. Much of the discussion seems to accept an implicit presumption that all clinical ethics consultation practices look pretty much alike. But is this accurate? What do clinical ethicists do, how and where do they do it, and what kind of clinical ethics is useful in the hospital and in other settings? (shrink)

Bioethics education now takes place outside universities as well as within them. How should clinicians, ethics committee members, and policymakers be taught the ethics they need, and how may their progress best be evaluated?

A major facet of the bioethics phenomenon in North America has been the emergence of a new profession on the healthcare turf: a growing number of people calling themselves or being called “bioethicists.” Bioethicists are plying their trade mainly as ethics consultants in hospital settings and as researchers and educators with university affiliations. Other more questionable affiliations can easily be imagined: Bioethicist for a controversial transplant program? For a lobby or advocacy group? For a pharmaceutical company?

The philosophical method is critical to ethics consulting. To be truly effective, ethicists need grounding in ethics theory, abstract reasoning and conceptual analysis. A Practical Guide to Clinical Ethics Consulting allows ethicists to understand problems from practitioners' points-of-view, and allows for a genuine appreciation of the working life of practitioners.

Bioethics education now takes place outside universities as well as within them. How should clinicians, ethics committee members, and policymakers be taught the ethics they need, and how may their progress best be evaluated?

Context: Although ethics consultation is commonplace in United States hospitals, descriptive data about this health service are lacking. Objective: To describe the prevalence, practitioners, and processes of ethics consultation in U.S. hospitals. Design: A 56-item phone or questionnaire survey of the “best informant” within each hospital. Participants: Random sample of 600 U.S. general hospitals, stratified by bed size. Results: The response rate was 87.4%. Ethics consultation services were found in 81% of all general hospitals in the U.S., and in 100% (...) of hospitals with more than 400 beds. The median number of consults performed by ECSs in the year prior to survey was 3. Most individuals performing ethics consultation were physicians, nurses, social workers, or chaplains. Only 41% had formal supervised training in ethics consultation. Consultation practices varied widely both within and between ECSs. For example, 65% of ECSs always made recommendations, whereas 6% never did. These findings highlight a need to clarify standards for ethics consultation practices. (shrink)

Whether ethics is too important to be left to the experts or so important that it must be is an age-old question. The emergence of clinical ethicists raises it again, as a question about professionalism. What role clinical ethicists should play in healthcare decision making – teacher, mediator, or consultant – is a question that has generated considerable debate but no consensus.

Boundaries in the doctor–patient relationshipis an important concept to help healthprofessionals navigate the complex andsometimes difficult experience between patientand doctor where intimacy and power must bebalanced in the direction of benefitingpatients. This paper reviews the concept ofboundary violations and boundary crossings inthe doctor–patient relationship, cautions aboutcertain kinds of boundary dilemmas involvingdual relationships, gift giving practices,physical contact with patients, andself-disclosure. The paper closes with somerecommendations for preventing boundaryviolations.

Is bioethics consultation a profession? Withfew exceptions, the arguments andcounterarguments about whether healthcareethics consultation is a profession haveignored the historical and cultural developmentof professions in the United States, the wayssocial changes have altered the work andboundaries of all professions, and theprofessionalization theories that explain howmodern societies institutionalize expertise inprofessions. This interdisciplinary analysisbegins to fill this gap by framing the debatewithin a larger theoretical context heretoforemissing from the bioethics literature. Specifically, the question of whether ethicsconsultation is a profession is examined fromthe (...) perspectives of trait theory, Wilensky''sfive-stage process of professionalization,Abbott''s interdependent system of professions,and Haug''s deprofessionalization thesis. Whilehealthcare ethics consultation does not meetthe criteria to claim professional status,neither could most professions pass these idealtheoretical standards. Instead of a yes or nodichotomous response to the question, it ismore helpful to envision a professionalizationcontinuum with sales clerks or carpenters atone end and medicine or law at the other. During the past decade healthcare ethicsconsultation has been moving along thiscontinuum toward greater professional status. (shrink)

Bioethics traditionally focuses on establishing moral limits between different types of acts. However, boundaries are established by communities and individuals who differ in the constraints shaping their moral world. Phase boundaries, the sites of transition between two physical phases such as a liquid and a gas, provide a metaphor for ‘drawing a line’ in bioethics discourse. Phase boundaries occur where the physical constraints allow both phases to coexist in stable equilibrium. This relationship can also be considered in reverse, using the (...) known position of the phase boundary to disclose the physical constraints. By analogy, instead of trying to locate the ‘correct’ moral boundary, the alternative perspective of ‘reverse ethics’ works from a commonly accepted boundary to examine the constraints of the moral world that are being used to establish it. Genetic interventions into the human body provide interesting examples of boundary establishment. In gene therapy, focusing on boundaries has resulted in a model of moral permissibility that ignores some alternative standpoints and increases the potential for conflict between them. Reverse ethics examines such conflicts in terms of the nature of the moral worlds that have come into contact with each other, taking seriously the diversity of factors governing the location of a boundary, in ways that might help shift some entrenched lines of conflict. (shrink)