In its recent statement 'Sex Selection and Preimplantation Genetic Diagnosis', the Ethics Committee of the American Society of Reproductive Medicine concluded that preimplantation genetic diagnosis for sex selection for non-medical reasons should be discouraged because it poses a risk of unwarranted gender bias, social harm, and results in the diversion of medical resources from genuine medical need. We critically examine the arguments presented against sex selection using preimplantation genetic diagnosis. We argue that sex selection should be available, at (...) least within privately funded health care. (shrink)

Since the Supreme Court upheld the partial birth abortion ban in 2007, more U.S. abortion providers have begun performing intraamniotic digoxin injections prior to uterine dilation and evacuations. These injections can cause medical harm to abortion patients. Our objective is to perform an in-depth bioethical analysis of this procedure, which is performed mainly for the provider’s legal benefit despite potential medical consequences for the patient.

Artificial intelligence (AI) systems have demonstrated impressive performance across a variety of clinical tasks. However, notoriously, sometimes these systems are 'black boxes'. The initial response in the literature was a demand for 'explainable AI'. However, recently, several authors have suggested that making AI more explainable or 'interpretable' is likely to be at the cost of the accuracy of these systems and that prioritising interpretability in medical AI may constitute a 'lethal prejudice'. In this paper, we defend the value of interpretability (...) in the context of the use of AI in medicine. Clinicians may prefer interpretable systems over more accurate black boxes, which in turn is sufficient to give designers of AI reason to prefer more interpretable systems in order to ensure that AI is adopted and its benefits realised. Moreover, clinicians may be justified in this preference. Achieving the downstream benefits from AI is critically dependent on how the outputs of these systems are interpreted by physicians and patients. A preference for the use of highly accurate black box AI systems, over less accurate but more interpretable systems , may itself constitute a form of lethal prejudice that may diminish the benefits of AI to - and perhaps even harm - patients. (shrink)

Artificial intelligence (AI) systems have demonstrated impressive performance across a variety of clinical tasks. However, notoriously, sometimes these systems are “black boxes.” The initial response in the literature was a demand for “explainable AI.” However, recently, several authors have suggested that making AI more explainable or “interpretable” is likely to be at the cost of the accuracy of these systems and that prioritizing interpretability in medical AI may constitute a “lethal prejudice.” In this paper, we defend the value of interpretability (...) in the context of the use of AI in medicine. Clinicians may prefer interpretable systems over more accurate black boxes, which in turn is sufficient to give designers of AI reason to prefer more interpretable systems in order to ensure that AI is adopted and its benefits realized. Moreover, clinicians may be justified in this preference. Achieving the downstream benefits from AI is critically dependent on how the outputs of these systems are interpreted by physicians and patients. A preference for the use of highly accurate black box AI systems, over less accurate but more interpretable systems, may itself constitute a form of lethal prejudice that may diminish the benefits of AI to—and perhaps even harm—patients. (shrink)

Loneliness in medicine is a serious problem not just for patients, for whom illness is intrinsically isolating, but also for physicians in the contemporary condition of medicine. We explore this problem by investigating the ideal physician-patient relationship, whose analogy with friendship has held enduring normative appeal. Drawing from Talbot Brewer and Nir Ben-Moshe, we argue that this appeal lies in a dynamic form of companionship incompatible with static models of friendship-like physician-patient relationships: a mutual refinement of embodied (...) virtue that draws both persons together. The ideal physician-patient relationship has a dialectical character that fosters each member's improvement of phenomenologically recognizing and embodying moral virtues. A key component of this dynamic is a commitment to the common goal of the patient's health, realized through joint interactivities and conversations over time. The physician's presence to the patient's suffering—understood best as an alienating phenomenological condition for the patient—orients and discloses possibilities for virtuous caregiving by structuring the meanings of the goals, conversations, and joint narrative constitutive of their relationship. Presence to suffering, paradoxically, is perhaps an important prerequisite for this dynamic partnership. These activities dialectically build an interpretive horizon of understanding through which moral goods and character refinement—in and for the other—may become revealed for both persons in their shared being-in-the-world. This analysis of suffering, mood, and revealing of (possible) moral goods has implications for addressing the modern problem of loneliness for patients and physicians, who are increasingly inhibited from building flourishing relationships with each other. (shrink)

In Deep Medicine, Eric Topol argues that the development of artificial intelligence (AI) for healthcare will lead to a dramatic shift in the culture and practice of medicine. Topol claims that, rather than replacing physicians, AI could function alongside of them in order to allow them to devote more of their time to face-to-face patient care. Unfortunately, these high hopes for AI-enhanced medicine fail to appreciate a number of factors that, we believe, suggest a radically different (...) picture for the future of healthcare. Far from facilitating a return to “the golden age of doctoring”, the role of economic and institutional considerations in determining how medical AI will be used mean that it is likely to further erode therapeutic relationships and threaten professional and patient satisfaction. (shrink)

In a recent Response published in the Journal of Medical Ethics,1 Buturovic provides two criticisms of my argument in ‘Is the exclusion of psychiatric patients from access to physician-assisted suicide discriminatory?’2 First, Buturovic argues that my argument effectively ‘erases the distinction between healthy adults and patients (whether somatic or psychiatric) essentially implying that PAS [physician-assisted suicide] should be available to all, for all reasons or, ultimately no reason’ (Buturovic,1 pg. 1). Second, Buturovic argues that opening the doors to medical assistance (...) in dying (MAID) for psychiatric patients could have a number of undesirable implications. In particular, Buturovic highlights the potential negative implications for relations of trust in medicine—psychiatry in particular—along with potential effects on the rate of organ donation. I would here like to respond to these two criticisms. In short, my response to Buturovic’s first argument is that the slope is not nearly as slippery as Buturovic suggests. The reason for this is that the plausibility of Buturovic’s argument rests on a significant misinterpretation of my argument, along with an important equivocation in her own. Buturovic argues that, under the three criteria that I propose for the provision of MAID—sufficient decision-making capacity, demonstrated treatment resistance, and a lack of substantially negative implications for existing standards of psychiatric treatment and research—the provision of MAID for trivial reasons, even no reason at all, is justifiable. The main problem with this argument is that I propose no such positive criteria. My argument is that none of the three arguments addressed in my previous paper are sufficient to justify the exclusion of any and all psychiatric patients from access to MAID. I do not claim, in other words, that any individual …. (shrink)

Lilly was one of the greatest scientists and pioneers on the limits of human possibility but after his death a collective amnesia has descended and he is now almost forgotten. His Wiki is good but inevitably incomplete so here are a few missing details and viewpoints. Lilly was a generation (or more) ahead of his time. He is almost single-handedly responsible for the great interest in dolphins (which led to the Marine Mammal Protection Act in the USA and helped (...) to found the animal rights movement). In 1958 he noted that the brains of elephants and cetaceans were larger than ours, that we should not abuse them and that it was one our most important projects to communicate with them. He invented sensory isolation tanks (at NIMH in 1954) and used them extensively with and without powerful psychoactive drugs at a time when it was thought that either the brain would shut down or one would go insane if external stimuli were eliminated. He created methods for implanting electrodes in mammal brains and was planning to do it to himself. He was one of the first to make serious use of computers in bioscience research and created the hardware and software to make the first attempts to communicate with dolphins. He self experimented with dangerous physiological investigations in high altitude medicine for the military during WW2, took LSD with dolphins and movie stars, submitted himself to the rigors of various forms of yoga and of Arica training, and taught classes at Esalen. He was a computer pioneer who forsaw the rapid advances in A.I. and it's inevitable clash with humans. He was the first one to investigate the bizarre psychedelic ketamine (" vitamin K "), and his results (published in the two last chapters of his book `The Scientist`) are still the best data on the dose/effect relation of any psychedelic on one person. It cured his lifelong daily migraine headaches (see http://www.conspiracyarchive.com/UFOs/Gorightly.htm). And all this happened before most of us were born! He had courage, honesty and integrity that is rare anywhere and almost nonexistent in science. His goal was to find the ultimate truth about everything and he went about as far as anyone ever has. He had little patience with the stupid and hypocritical games one has to play to fit into monkey society. Of course the reaction of the establishment was predictable. He left the NIMH and was never given any government or academic support for the last 35 years of his life. His paper and comments at a conference on sensory deprivation were removed from the published version. He was not invited to government sponsored symposia on dolphins (he had refused to help develop them as weapons), though he clearly knew more about them than anyone in the world. He liked to live and work on the edge and few could keep up with him, as his books make clear. If you have read some of his other books it will be much easier going. He was a pioneer in consciousness research and pushed the boundaries of our understanding of who we are and what we might become. Among other things he catalogs the various states reached by drugs, meditation, and isolation, tries to determine their significance, and suggests how to use them. I very briefly review and comment on his life and work. -/- Those interested in all my writings in their most recent versions may download from this site my e-book ‘Philosophy, Human Nature and the Collapse of Civilization Michael Starks (2016)- Articles and Reviews 2006-2016’ by Michael Starks First Ed. 662p (2016). -/- All of my papers and books have now been published in revised versions both in ebooks and in printed books. -/- Talking Monkeys: Philosophy, Psychology, Science, Religion and Politics on a Doomed Planet - Articles and Reviews 2006-2017 (2017) https://www.amazon.com/dp/B071HVC7YP. -/- The Logical Structure of Philosophy, Psychology, Mind and Language in Ludwig Wittgenstein and John Searle--Articles and Reviews 2006-2016 (2017) https://www.amazon.com/dp/B071P1RP1B. -/- Suicidal Utopian Delusions in the 21st century: Philosophy, Human Nature and the Collapse of Civilization - Articles and Reviews 2006-2017 (2017) https://www.amazon.com/dp/B0711R5LGX -/- . (shrink)

Perez-Rodriguez and de la Fuente (2017) assume that although human races do not exist in a biological sense (“geneticists and evolutionary biologists generally agree that the division of humans into races/subspecies has no defensible scientific basis,” they exist only as “sociocultural constructions” and because of that maintain an illusory reality, for example, through “racialized” practices in medicine. Agreeing with the main postulates formulated in the article, we believe that the authors treat this problem in a superficial manner and have (...) failed to capture the current state of the field of knowledge in science and the humanities. In our commentary, we want to highlight two main omissions, and to notice three important implications for “a postracial medicine.”. (shrink)

The Psychological Society of Ireland’s (PSI) response to the call from the United Nations (UN) Committee on the Rights of the Child: Draft General Comment No. 26 Calls for comment on the draft general comment on children’s rights and the environment with a special focus on climate change III. ‘Specific rights of the Convention as they relate to the environment’, B. The right to the highest attainable standard of health (art. 24), 27. … children’s current and anticipated psychosocial, emotional (...) and mental health problems and suffering caused by environmental harm. The PSI wishes to express sincere thanks to the Society’s Special Interest Group in Human Rights and Psychology, particularly Dr Michelle Cowley-Cunningham, Dr Elaine Rogers, and Ms Alexis Carey, who coordinated the following response on behalf of the Society. 1. Environmental degradation, loss of biodiversity, and climate change impact children’s human rights and present a serious threat to future generations’ enjoyment of human rights. Distressingly, 1.7 million children lose their lives annually as a result of avoidable environmental impacts, while millions more are impacted by disease, displaced from their homes and miss out on receiving education1. The PSI Special Interest Group in Human Rights and Psychology (SIGHRP) is grateful to the Committee on the Rights of the Child for this opportunity to submit a stakeholder comment in advance of the drafting of the Draft General Comment No. 26. SIGHRP is appreciative of the work of the Committee in monitoring the implementation of the Convention on the Rights of the Child (UNCRC) and welcomes the Committee's stakeholder call for ideas to aid the development of policies, both domestically and internationally, to address critical climate change issues. Specifically, SIGHRP welcomes the opportunity to comment on the connection between child and adolescent mental health and human rights obligations, and advocates for policies and initiatives to address this issue in the context of climate change. (shrink)

According to recent approaches in the philosophy of medicine, biomedicine should be replaced or complemented by a humanistic medical model. Two humanistic approaches, narrative medicine and the phenomenology of medicine, have grown particularly popular in recent decades. This paper first suggests that these humanistic criticisms of biomedicine are insufficient. A central problem is that both approaches seem to offer a straw man definition of biomedicine. It then argues that the subsequent definition of humanism found in these approaches (...) is problematically reduced to a compassionate or psychological understanding. My main claims are that humanism cannot be sought in the patient–physician relationship alone and that a broad definition of medicine should help to revisit humanism. With this end in view, I defend what I call an outcomes-oriented approach to humanistic medicine, where humanism is set upon the capacity for a health system to produce good health outcomes. (shrink)

Purpose: The objective of this study is to determine the importance of supplementary medical ethics course for resident physicians. In this study, we assessed the current state of their knowledge of medical ethics and aimed to improve and deepen their understanding of clinical scenarios to increase their awareness of the link between the practice of medicine and ethical issues. Methods: The course was held for groups of 10-12 people for 3 days a week for a total of 6 (...) hours. Tests given prior to and following completion of the course were used to assess the effectiveness of a medical ethics training course in which 120 resident physicians completed. The evaluation was made on the basis of the same pre-and post-tests (14 scenarios) and direct observation of participants. Result and Discussion: The average age was 28.23 ± 4.08 and 25% were female and 75% were male. Of the participants, 68.3% were training to be internists, 24.2% were training to be surgeons, and 7.5% were training in laboratory medicine. There was a significant statistical difference between the mean total scores of both tests (p=0.00). After completing the course, residents took into account the medical ethical principles while discussing ethical decisions. Conclusion: After finishing the course, participants defended their responses in regard to issues of medical ethics more carefully and articulated their thoughts more clearly. Our experience demonstrated that the trainees benefited from a structured curriculum in medical ethics. We believe that the development and implementation of our course may serve as a case study for training resident physicians in medical ethics. (shrink)

Most people who defend physician-assisted death (PAD) endorse the Joint View, which holds that two conditions—autonomy and welfare—must be satisfied for PAD to be justified. In this paper, we defend an Autonomy Only view. We argue that the welfare condition is either otiose on the most plausible account of the autonomy condition, or else is implausibly restrictive, particularly once we account for the broad range of reasons patients cite for desiring PAD, such as “tired of life” cases. Moreover, many of (...) the common objections to an Autonomy Only view fail once we understand the extent of the autonomy condition’s requirements—in particular, the importance of one’s values for autonomous choices. If our view is correct, then the scope of permissible PAD is broader than is currently accepted in both the philosophical literature and the law, and therefore poses an important challenge to this widely accepted view on justified PAD. (shrink)

According to Aristotle, the medical art aims at health, which is a virtue of the body, and does so in an unlimited way. Consequently, medicine does not determine the extent to which health should be pursued, and “mental health” falls under medicine only via pros hen predication. Because medicine is inherently oriented to its end, it produces health in accordance with its nature and disease contrary to its nature—even when disease is good for the patient. Aristotle’s politician (...) understands that this inherent orientation can be systematically distorted, and so would see the need for something like the Hippocratic Oath. (shrink)

Jake Greenblum and Ryan K Hubbard argue that physicians, nurses, clinical ethicists and ethics committee members should not cite religious considerations when helping patients (or their proxies) make medical decisions. They provide two arguments for this position: The Public Reason Argument and the Fiduciary Argument. In this essay, I show that the Public Reason Argument fails. Greenblum and Hubbard may provide good reason to think that physicians should not invoke their own religious commitments as reasons for a (...) particular medical decision. But they fail to show that it is wrong for physicians to cite the patient’s own religious commitments as reasons for a particular decision. As such, if Greenblum and Hubbard’s thesis is to survive, the Fiduciary Argument (or some unmentioned argument) will have to do the bulk of the work. (shrink)

Kant and Medicine - the Philosopher as Anthropologist, Physician and Patient. It remains uncertain whether the student Immanuel Kant (1724-1804) truly wanted to become a physician or only said this in order to please a sponsor. Due to his narrow chest and other typical weaknesses of a scholar he considered himself a hypochondriac and cautiously kept his distance from dangerous illnesses, especially those of the mind. He inspired his students - including Herder, Herz, Lenz and Hoffmann - far less (...) with logic and metaphysics than with exciting findings about far away countries, their alien inhabitants and the health dangers lurking in exotic parts of the world. He called for philosophical treatment of physical illnesses beyond the limited "veterinary" approach of medicine. He claimed the responsibility of the philosophy faculty for forensic questions. Kant developed original ideas about the seat of the soul, which led to the construction of a first model of the brain including functioning synapses. He was unable to overcome reservations about smallpox vaccination because he feared a change in the germ line. He wanted to see "how long the stuff would last" and during his later decades used all the classic dietetics to successfully extend his life. These sex res non-naturales continue to play a significant role in the prevention of widespread diseases today. Then an "electric revolution of the air strata" took its toll on him. Towards the end, his confidants were to look at him like a child, who, however, left posterity an extensive work with deep insights into his thinking, the Opus postumum. (shrink)

Physicians frequently ask whether they should give patients what they want, usually when there are considerations pointing against doing so, such as medicine’s values and physicians’ obligations. It has been argued that the source of medicine’s values and physicians’ obligations lies in what has been dubbed “the internal morality of medicine”: medicine is a practice with an end and norms that are definitive of this practice and that determine what physicians ought to (...) do qua physicians. In this paper, I defend the claim that medicine requires a morality that is internal to its practice, while rejecting the prevalent characterization of this morality and offering an alternative one. My approach to the internal morality of medicine is constructivist in nature: the norms of medicine are constructed by medical professionals, other professionals, and patients, given medicine’s end of “benefitting patients in need of prima facie medical treatment and care.” I make the case that patients should be involved in the construction of medicine’s morality not only because they have knowledge that is relevant to the internal morality of medicine—namely, their own values and preferences—but also because medicine is an inherently relational enterprise: in medicine the relationship between physician and patient is a constitutive component of the craft itself. The framework I propose provides an authoritative morality for medicine, while allowing for the incorporation, into that very morality, of qualified deference to patient values. (shrink)

In this paper I analyze a view that is increasingly spreading among philosophers and even physicians. Many of them believe that it is right to apply the principle of responsibility for illness in the allocation of health care. I attempt to show that this idea is unacceptable.

The Netherlands was the first country to legalize euthanasia and physician-assisted suicide. This paper offers a first legal perspective on the prospects of using AI in the Dutch practice of euthanasia and physician-assisted suicide. It responds to the Regional Euthanasia Review Committees’ interest in exploring technological solutions to improve current procedures. The specific characteristics of AI – the capability to process enormous amounts of data in a short amount of time and generate new insights in individual cases – may for (...) example alleviate the increased workload of review committees due to the continuous increase of euthanasia cases. The paper considers three broad categories for the use of AI in the Dutch euthanasia practice: (1) the physician’s assessment of euthanasia requests, (2) the actual execution of euthanasia, and (3) the retrospective reviews of cases by the Regional Euthanasia Review Committees. Exploring the legal considerations around each avenue, both in the EU AI Act and the Dutch legal framework, this paper aims to facilitate the societal discussion on the role of technology in such deeply human decisions. This debate is equally relevant to other countries that legalized euthanasia (e.g. Belgium and Canada) or physician-assisted suicide (e.g. Switzerland and numerous states in the US). (shrink)

he Handbook constitutes a global resource for the fast growing interdisciplinary research and policy communities addressing the challenge of driving innovation towards socially desirable outcomes. This book brings together well-known authors from the US, Europe, Asia and South-Africa who develop conceptual, ethical and regional perspectives on responsible innovation as well as exploring the prospects for further implementation of responsible innovation in emerging technological practices ranging from agriculture and medicine, to nanotechnology and robotics. The emphasis is on the (...) socio-economic and normative dimensions of innovation including issues of social risk and sustainability. (shrink)

This paper investigates the scope and limits of parents' and physicians' obligations to anencephalic newborns. Special attention is paid to the permissibility of harvesting anencephalic organs for transplant. My starting point is to identify the general justification for treating patients in order to benefit third parties. This analysis reveals that the presence of a close relationship between patients and beneficiaries is often crucial to justifying treating in these cases. In particular, the proper interpretation of the Kantian injunction against treating (...) persons as means only takes on a different light in the context of special relationships. The implications of this analysis for our responsibilities to anencephalic infants is clarified. (shrink)

The reemergence of the question of suicide in the medical context of physician-assisted suicide seems to me one of the most interesting and fertile facets of late modernity. Aside from the disruption which this issue may cause in the traditional juridical relationship between individuals and the state, it may also help to transform the dominant conception of subjectivity that has been erected upon modernity's medicalized order of death. To enhance this disruptive potential, I am going to examine the perspectives on (...) death offered by two contemporary writers: Zygmunt Bauman and Jean Baudrillard. Each of these writers recognizes the centrality of death to modern culture, as Heidegger did, but they also go beyond him in specifying the ways in which death maintains a presence in late modernity, despite efforts to conceal it. In particular, both of these writers recognize the important role that medicine has played in ordering the modern conception of death. After situating these two perspectives in relation to each other, and in relation to Heidegger, who will serve here as a sort of benchmark, I will return to the issue of suicide. Given the differences in their readings of the role that death and medicine play in modern culture, these post-Heideggerians take strikingly different positions on this issue. By engaging these perspectives, I intend not only to point out the tremendous potential which this issue holds for a fundamental rethinking of modern subjectivity, but also reveal some of the dangers that may beset any naive optimism about the right to die. (shrink)

Narratives have come to influence medicine, giving rise to a new approach called "narrative medicine". In this paper, we consider the patient as a text, an open book in which physicians and healthcare professionals, but also from which they can and should learn a great deal. By delving into the narrative perspective of understanding the patient and their situation, we discover how the patient is the object of the physician's compassion, but also how he or she becomes (...) the subject of that compassion. We conclude that it is important for physicians to spend time in their undergraduate and graduate medical education exploring and using the value of narratives to help them categorize their lived experiences and those of patients. -/- As narrativas estão chegando a influenciar na medicina, dando origem a uma nova abordagem chamada " medi-cina narrativa ". Neste trabalho consideramos o paciente como um texto, em outras palavras, um livro aberto que o médico intervém, mas também, que deve aprender muito. Aprofundar-se um pouco na perspectiva narrativa da compreensão do paciente e de sua situação ajuda a descobrir como o paciente é objeto da compaixão dos médicos, embora também como se converte em sujeito desta compaixão. Concluímos que é importante que os médicos dediquem mais tempo em sua formação médica inicial, bem como em sua formação permanente, para explorar o valor das narrativas que ajudam a categorizar suas experiências e a dos pacientes. -/- Las narraciones han llegado a influir en la medicina, dando lugar a un nuevo enfoque llamado " medicina narrativa ". En este trabajo consideramos al paciente como un texto, es decir, un libro abierto que el médico interviene, pero también del que el médico puede y necesita mucho aprender. Ahondar un poco en la perspectiva narrativa de la comprensión del paciente y de su situación nos ayuda a descubrir cómo el paciente es objeto de la compasión de los médicos, pero también cómo se convierte en sujeto de esa compasión. Concluimos que es importante que los médicos dediquen tiempo en su formación médica inicial, así como en su formación permanente, a explorar y explotar el valor de las narraciones, que les ayuden a categorizar sus experiencias vividas y las de los pacientes. (shrink)

In times of crises, public health leaders may claim that trials of public health interventions are unethical. One reason for this claim can be that equipoise—i.e. a situation of uncertainty and/or disagreement among experts about the evidence regarding an intervention—has been disturbed by a change of collective expert views. Some might claim that equipoise is disturbed if the majority of experts believe that emergency public health interventions are likely to be more beneficial than harmful. However, such beliefs are not always (...) justified: where high quality research has not been conducted, there is often considerable residual uncertainty about whether interventions offer net benefits. In this essay we argue that high-quality research, namely by means of well-designed randomized trials, is ethically obligatory before, during, and after implementing policies in public health emergencies (PHEs). We contend that this standard applies to both pharmaceutical and non-pharmaceutical interventions, and we elaborate an account of equipoise that captures key features of debates in the recent pandemic. We build our case by analyzing research strategies employed during the COVID-19 pandemic regarding drugs, vaccines, and non-pharmaceutical interventions; and by providing responses to possible objections. Finally, we propose a public health policy reform: whenever a policy implemented during a PHE is not grounded in high-quality evidence that expected benefits outweigh harms, there should be a planned approach to generate high-quality evidence, with review of emerging data at preset time points. These preset timepoints guarantee that policymakers pause to review emerging evidence and consider ceasing ineffective or even harmful policies, thereby improving transparency and accountability, as well as permitting the redirection of resources to more effective or beneficial interventions. (shrink)

There is disagreement among physicians and medical ethicists on the precise goals of Hospice and Palliative Medicine (HPM). Some think that HPM's goals should differ from those of other branches of medicine and aim primarily at lessening pain, discomfort, and confusion; while others think that HPM's practices should, like all other branches of medicine, aim at promoting health. I take the latter position: using the ars moriendi to set a standard for what it means to die (...) well, I argue that if HPM's practices were to aim at mitigating suffering with little regard to promoting health, some patients would die worse deaths than if HPM's practices were to aim at health. According to the ars moriendi, flourishing at the end of one's life requires that one exercise her agency and pursue the goods most important to her. On this view, HPM's practices should promote patients’ health to enable them to pursue these goods. (shrink)

Physicians try hard to alleviate mental and physical ailments of their patients. Thus, they are heavily burdened by observing ethics and staying well-informed while improving health of their patients. A major ethical concern or dilemma in medication is that some physicians know their behavior is unethical, yet act against their moral compass. This study develops models of theory–practice gap, offering optimal solutions for the gap. These solutions would enhance self-motivation or remove external obstacles to stimulate ethical practices in (...) medicine. The Constructivist Grounded Theory Methodology is applied here where the participants and the main researcher mutually interacted with each other. Data collection was performed through qualitative methods including observation and semi-structured interviews with 21 physicians and medical students. Initial and focused coding was done, from which principal concepts were later extracted. MAXQDA software was used for analyzing data. Analysis of twelve major concepts in the study resulted in two factors and solution groups, from which four general notions influencing the ethical theory and practice gap in medicine were extracted: (1) providing effective education to change attitude and behavior; (2) considering motivational and emotional factors; (3) reconstructing regulations and processes to facilitate ethical practice; (4) conducting comprehensive and systematic studies. The existing medical educational system needs to be reconsidered to add to individual internal motivation, including optimizing persuasion strategies, maximizing participation of students, adhering to virtuous ethical theories, and fostering emotions. Additionally, regulations and processes can be reconstructed to remove practical obstacles and promote ethical practice with insignificant damages to individual self-motivation. (shrink)

The purpose of this study was to determine the attitudes, expectations, experiences, and barriers that physicians in Tripoli hospitals experienced when working alongside Clinical Pharmacists (CPs). A descriptive self-administered questionnaire was used for the study, and participants were selected from several Tripoli hospitals. Most of the respondents agreed that CPs are an essential part of patient care teams and that they have the legal authority to review a patient's medication regimen and response. More than half of respondents believe CPs (...) must be responsible for the medications they prescribe to patients. Half of the respondents agreed that CPs should be encouraged to play a more active role in hospitals and other healthcare facilities. The majority of participants agreed that CPs should participate in managing drug side effects and almost half agreed that CPs can contribute to decisions about drug interactions. By a low agreement rate, 42.7% of respondents thought CPs were specially qualified to counsel patients on drug therapy. A similar low trend was observed, with 40.9% agreeing to provide pharmacists with additional responsibility and authority in clinical departments, in contrast, 54.5% expressed their concern about the clinical responsibility of CPs in clinical practice. A minority of physicians agreed that Physicians should consult pharmacists in selecting the best pharmacological treatment. At the same time, the majority think that pharmacists lack clinical skills and 61.8% feel that physicians are unable to communicate effectively with CPs. 43.6% acknowledged that the traditional opposition between the two professions was a barrier to interprofessional collaboration while the absence of pharmacy space in clinical settings was cited by 39.1%. A majority of respondents agreed that physicians and pharmacists may improve their interprofessional collaboration by raising their awareness about it. A minority of respondents thought that laws and regulations governing physician collaboration should be put in place to promote effective collaboration between physicians and CPs. The study discovered that although most physicians endorse the introduction of clinical pharmacy services in hospitals and believe that physicians and pharmacists can collaborate on many tasks, respondents were not as impressed with the CPs' performance and believed that they lacked the professionalism required to carry out clinical responsibilities successfully. To facilitate the growth of clinical pharmacy services, laws and regulations must be put in place. (shrink)

This document presents the Bonn PRINTEGER Consensus Statement: Working with Research Integrity—Guidance for research performing organisations. The aim of the statement is to complement existing instruments by focusing specifically on institutional responsibilities for strengthening integrity. It takes into account the daily challenges and organisational contexts of most researchers. The statement intends to make research integrity challenges recognisable from the work-floor perspective, providing concrete advice on organisational measures to strengthen integrity. The statement, which was concluded February 7th 2018, provides guidance on (...) the following key issues: § 1. Providing information about research integrity§ 2. Providing education, training and mentoring§ 3. Strengthening a research integrity culture§ 4. Facilitating open dialogue§ 5. Wise incentive management§ 6. Implementing quality assurance procedures§ 7. Improving the work environment and work satisfaction§ 8. Increasing transparency of misconduct cases§ 9. Opening up research§ 10. Implementing safe and effective whistle-blowing channels§ 11. Protecting the alleged perpetrators§ 12. Establishing a research integrity committee and appointing an ombudsperson§ 13. Making explicit the applicable standards for research integrity. (shrink)

Organ transplantation centers set criteria for candidate qualification, which has led to disparate healthcare resource allocation practices affecting those with a substance use history. These individuals are denied organ transplants by committees and healthcare providers who assign them lower priority status. The lower priority argument claims that healthcare resources should not be provided equally to individuals who fail to share responsibility for not doing enough to address the diseases associated with substance use. The purpose of this paper is to explore (...) the interrelatedness between the ethics of a merit-based system of moral responsibility and the lower priority setting involved in healthcare resource allocation pertaining to those with substance use histories. An interdisciplinaryapproach to the argument against the lower prioritists is taken with a focus on the relationship between different organ allocation practices affecting substance users and the justification for resource allocation practices of healthcare and transplant committees. Lower priority setting is challenged, and an argument is offered in which substance users are assigned higher priority when relying on "doing enough" in a merit-based system of moral responsibility. It is determined that one cannot substantiate assigning a lower priority status since a lack of success in rehab does not imply a lack of effort. Additionally, neither to confirmatory behavior nor to non-conforming behavior may freedom be justifiably ascribed in a merit-based system of responsibility because freedom to choose can neither be established a priori nor a posteriori concerning meritorious behavior. (shrink)

What does Artificial Intelligence (AI) have to contribute to health care? And what should we be looking out for if we are worried about its risks? In this paper we offer a survey, and initial evaluation, of hopes and fears about the applications of artificial intelligence in medicine. AI clearly has enormous potential as a research tool, in genomics and public health especially, as well as a diagnostic aid. It’s also highly likely to impact on the organisational and business (...) practices of healthcare systems in ways that are perhaps under-appreciated. Enthusiasts for AI have held out the prospect that it will free physicians up to spend more time attending to what really matters to them and their patients. We will argue that this claim depends upon implausible assumptions about the institutional and economic imperatives operating in contemporary healthcare settings. We will also highlight important concerns about privacy, surveillance, and bias in big data, as well as the risks of over trust in machines, the challenges of transparency, the deskilling of healthcare practitioners, the way AI reframes healthcare, and the implications of AI for the distribution of power in healthcare institutions. We will suggest that two questions, in particular, are deserving of further attention from philosophers and bioethicists. What does care look like when one is dealing with data as much as people? And, what weight should we give to the advice of machines in our own deliberations about medical decisions? (shrink)

Over the past 25 years, several new “medicines” have come screeching onto health care’s various platforms, including narrative medicine, personalized medicine, precision medicine and person-centred medicine. Philosopher Miriam Solomon calls the first three of these movements different “ways of knowing” or “methods,” and argues that they are each a response to shortcomings of methods that came before them. They should also be understood as reactions to the current dominant model of medicine. In this article, I (...) will describe our dominant model, which I call “the new medical model.” I will argue that several towering problems in modern medicine can be traced to its philosophical foundations, which calls for philosophical analysis. (shrink)

Is there a response, which is not accounted for by regression to the mean, natural history, the Hawthorne effect?The term placebo comes to us from the Latin for "I shall please," indicating that the phenomenon known as the "placebo effect" or "placebo response" has been familiar to medical practitioners for a number of centuries, at least. As we reached the mid-20th century and randomized controlled trials became a central feature of medical research, the use of controls and blinding in those (...) trials allowed for the isolation of the placebo effect in ways that made it much clearer that there... (shrink)

Mismatch is a prominent concept in evolutionary medicine, and a number of philosophers have published analyses of this concept. The word ‘mismatch’ has been used in a diversity of ways across a range of sciences, leading these authors to regard it as a vague concept in need of philosophical clarification. Here, in contrast, we concentrate on the use of mismatch in modelling and experimentation in evolutionary medicine. This reveals a rigorous theory of mismatch within which the term ‘mismatch’ (...) is indeed used in several ways, not because it is ill defined but because different forms of mismatch are distinguished within the theory. Contemporary evolutionary medicine has unified the idea of ‘evolutionary mismatch’, derived from the older idea of ‘adaptive lag’ in evolution, with ideas about mismatch in development and physiology derived from the developmental origins of health and disease (DOHaD) paradigm. A number of publications in evolutionary medicine have tried to make this theoretical framework explicit. We build on these to present the theory in as simple and general a form as possible. We introduce terminology, largely drawn from the existing literature, to distinguish the different forms of mismatch. This integrative theory of mismatch captures how organisms track environments across space and time on multiple scales in order to maintain an adaptive match to the environment, and how failures of adaptive tracking lead to disease. Mismatch is a productive organizing concept within this theory that helps researchers articulate how physiology, development, and evolution interact with one another and with environmental change to explain health outcomes. (shrink)

As national and state health care policy -making becomes contentious and complex, there is a need for a forum to debate and explore public concerns and values in health care, give voice to local citizens, to facilitate consensus among various stakeholders, and provide feedback and direction to health care institutions and policy makers. This paper explores the role that regional health care ethics committees can play and provides two contrasting examples of Networks involved in facilitation of public input into and (...) the development of health care policies and adoption of state-wide practices. (shrink)

In the last decade there has been a movement towards facilitating Open Access to academic outputs via the World Wide Web. This movement has been characterised as one that embodies corporate citizenship because such sharing has the potential to benefit all stakeholders: academics, policy makers, charitable sectors and the wider public. In the UK, the Economic and Social Research Council are implementing Open Access compliance guidelines for research that they fund, which is interpreted by individual institutions in their school regulations. (...) In the case of doctoral theses, there is now a requirement for students to provide an electronic format of their final work to be included in their school's online digital repository. In a number of UK institutions, University Awards and Progress Committees will only consider awarding the doctoral degree once these requirements have been satisfied. Although this move to Open Access can be considered as an egalitarian endeavour, this paper argues that an important stakeholder may have been overlooked in the march towards progressive dissemination. The temporal space between gaining informed consent from research participants and the changing nature of the accessibility of outputs can both engender a breach of ethics in terms of the initial agreements negotiated with participants and raise issues around representation in the ongoing dissemination and reformulation of the original work, particularly where visual images are central to research outputs. The paper utilises autoethnography and poetry to reflect on my own encounter with the requirement for Open Access and the ways in which this brings up concerns around ethics, obligations and integrity. (shrink)

On 4 December 2006, during discussions on the Corporate Manslaughter and Corporate Homicide Bill, Andrew Dismore, Member of Parliament and then Chair of the Joint Committee on Human Rights, said, ‘Organisations can kill people … but it is the actions and omissions of people in organisations that cumulatively cause death’. However, the corporate entity is a vehicle for the communal actions of those who guide the business activities. Attempting to seek out persons or people that are solely responsible (...) for deaths and violations of human rights caused by companies is fruitless. The entity is a vehicle for those actions, it possesses its own, often deep, pockets of finance and resources, and it has a public image. It is more useful to punish the corporate entity, in instances where the corporate behaviour has led to death and human rights abuses, as it is in seeking out individual defendants. Soft law options have not brought about a sufficient reduction in instances of deaths caused by corporate behaviour across jurisdictional borders. This article will argue that the time has now come to establish an international hard law on corporate killing, and for states to ensure that there is a viable path towards a redress for victims and their families along with adopting a duty to assist the victim or their family to pursue redress to ensure a fair balance of power against transnational companies. (shrink)

While every health care system stakeholder would seem to be concerned with obtaining the greatest value from a given technology, there is often a disconnect in the perception of value between a technology’s promoters and those responsible for the ultimate decision as to whether or not to pay for it. Adopting an empirical ethics approach, this paper examines how five Canadian medical device manufacturers, via their websites, frame the corporate “value proposition” of their innovation and seek to respond to (...) what they consider the key expectations of their customers. Our analysis shows that the manufacturers’ framing strategies combine claims that relate to valuable socio-technical goals and features such as prevention, efficiency, sense of security, real-time feedback, ease of use and flexibility, all elements that likely resonate with a large spectrum of health care system stakeholders. The websites do not describe, however, how the innovations may impact health care delivery and tend to obfuscate the decisional trade-offs these innovations represent from a health care system perspective. Such framing strategies, we argue, tend to bolster physicians’ and patients’ expectations and provide a large set of stakeholders with powerful rhetorical tools that may influence the health policy arena. Because these strategies are difficult to counter given the paucity of evidence and its limited use in policymaking, establishing sound collective health care priorities will require solid critiques of how certain kinds of medical devices may provide a better (i.e., more valuable) response to health care needs when compared to others. (shrink)

The Pneumatist school of medicine has the distinction of being the only medical school in antiquity named for a belief in a part of a human being. Unlike the Herophileans or the Asclepiadeans, their name does not pick out the founder of the school. Unlike the Dogmatists, Empiricists, or Methodists, their name does not pick out a specific approach to medicine. Instead, the name picks out a belief: the fact that pneuma is of paramount importance, both for explaining (...) health and disease, and for determining treatments for the healthy and sick. In this paper, we re-examine what our sources say about the pneuma of the Pneumatists in order to understand what these physicians thought it was and how it shaped their views on physiology, diagnosis and treatment. (shrink)

Sports physicians are continuously confronted with new biotechnological innovations. This applies not only to doping in sports, but to all kinds of so-called enhancement methods. One fundamental problem regarding the sports physician's self-image consists in a blurred distinction between therapeutic treatment and non-therapeutic performance enhancement. After a brief inventory of the sports physician's work environment I reject as insufficient the attempts to resolve the conflict of the sports physician by making it a classificatory problem. Followed by a critical assessment (...) of some ideas from the US President's Council on Bioethics, the formulation of ethical codes and attempts regarding a moral topography, it is argued that the sports physician's conflict cannot be resolved by the distinction between therapy and enhancement. Instead, we also have to consider the possibility that the therapy-based paradigm of medicine cannot do justice to the challenges of the continuously increasing technical manipulability of the human body and even our cognitive functions as well. At the same time we should not adhere to transhumanist ideas, because non-therapeutic interventions require clear criteria. Based on assistive technologies an alternative framework can be sketched that allows for the integration of therapeutic and non-therapeutic purposes. After a thorough definition of standards and criteria, the role of the sports physician might be defined as that of an assistant for enhancement. Yet the process of defining such an alternative framework is a societal and political task that cannot be accomplished by the sports physicians themselves. Until these questions are answered sports physicians continue to find themselves in a structural dilemma that they partially can come to terms with through personal integrity. (shrink)

I. EXECUTIVE SUMMARY The MRCT Center Post-trial Responsibilities: Continued Access to an Investigational Medicine Framework outlines a case-based, principled, stakeholder approach to evaluate and guide ethical responsibilities to provide continued access to an investigational medicine at the conclusion of a patient’s participation in a clinical trial. The Post-trial Responsibilities (PTR) Framework includes this Guidance Document as well as the accompanying Toolkit. A 41-member international multi-stakeholder Workgroup convened by the Multi-Regional Clinical Trials Center of Brigham and Women’s Hospital and (...) Harvard University (MRCT Center) developed this Guidance and Toolkit. Project Motivation A number of international organizations have discussed the responsibilities stakeholders have to provide continued access to investigational medicines. The World Medical Association, for example, addressed post-trial access to medicines in Paragraph 34 of the Declaration of Helsinki (WMA, 2013): “In advance of a clinical trial, sponsors, researchers and host country governments should make provisions for post-trial access for all participants who still need an intervention identified as beneficial in the trial. This information must also be disclosed to participants during the informed consent process.” This paragraph and other international guidance documents converge on several consensus points: • Post-trial access (hereafter referred to as “continued access” in this Framework [for terminology clarification – see definitions]) is the responsibility of sponsors, researchers, and host country governments; • The plan for continued access should be determined before the trial begins, and before any individual gives their informed consent; • The protocol should delineate continued access plans; and • The plan should be transparent to potential participants and explained during the informed consent process. -/- However, there is no guidance on how to fulfill these responsibilities (i.e., linking specific responsibilities with specific stakeholders, conditions, and duration). To fill this gap, the MRCT Center convened a working group in September of 2014 to develop a framework to guide stakeholders with identified responsibilities. This resultant Framework sets forth applicable principles, approaches, recommendations and ethical rationales for PTR regarding continued access to investigational medicines for research participants. (shrink)

There is a middle ground of imperfect knowledge in fields like medicine and the social sciences. It stands between our day-to-day relatively certain knowledge obtained from ordinary basic observation of regularities in our world and our knowledge from well-validated theories in the physical sciences. -/- The latter enable reliable prediction a great deal of the time of the happening of events never before experienced. The former enable prediction only of what has happened before and beyond that of educated guesses (...) which may sometimes prove right and others not when we test them. -/- The imperfection of our knowledge between those limits is a consequence of complexity. -/- Reductionist empiricism fails when faced with complexity but we all still have to live in a complex world where reductionist science cannot help us devise reliable theories from which we can predict the behaviour of the world around us. We cannot predict reliably. We can only monitor actively and manage actively the world around us if we want to try to control our environment. We have a limited prediction horizon. -/- Science and empiricism work well if we want to send Voyager I and II over 3 billion miles away but not for most other things. -/- In medicine how and when to apply probabilistic, conjectural, incomplete medical theories and explanations requires professional expertise, intuition and judgement (non scientific knowledge) which is essential. Medical diagnosis is a skill of predicting from knowledge of what has happened before that the past will recur in the current patient applying expertise and intuition from knowledge and experience of prior cases and probabilistic medical research and theory. The physician is left to an educated guess as to how the future will develop for the particular individual patient the focus of his or her current attention. (shrink)

We argue that deliberative decision-making that is inclusive, transparent and accountable can contribute to more trustworthy and legitimate decisions on difficult ethical questions and political trade-offs during the pandemic and beyond.

Clinical Ethics Consultations are an important tool for physicians in solving difficult cases. They are extremely common in North America and to a lesser extent also present in Europe. However, there is little data on this practice in Poland. We present results of a survey of 521 physicians practising in Poland concerning their opinion on CECs and related practices. We analysed the data looking at such issues as CECs’ perceived availability, use of CECs, and perceived usefulness of such (...) support. Physicians in our study generally encounter hard ethics cases, even—surprisingly—those who do not work in hospitals. Most physicians have no CEC access, and those that do still do not employ CECs. However, physicians perceive this form of support as useful—even more so among actual users of CECs. We compared these findings with similar studies from other European countries and the North America. We point out peculiarities of our results as compared to those in other countries, with some possible explanations. We hope the results may encourage regulatory debate on the need to formally introduce CECs into the Polish healthcare system. (shrink)

The practice of assigning authorship for a scientific publication tends to raise two normative questions: 1) ‘who should be credited as an author?’; 2) ‘who should not be credited as an author but should still be acknowledged?’. With the publication of the revised version of The European Code of Conduct for Research Integrity (ECCRI), standard answers to these questions have been called into question. This article examines the ways in which the ECCRI approaches these two questions and compares these approaches (...) to standard definitions of ‘authorship’ and ‘acknowledgment’ in guidelines issued by the International Committee of Medical Journal Editors (ICMJE) and the World Association of Medical Editors (WAME). In light of two scenarios and the problems posed by these kinds of ‘real-world’ examples, we recommend specific revisions to the content of the ECCRI in order not only to provide a more detailed account of the tasks deserving of acknowledgment, but to improve the Code’s current definition of authorship. (shrink)

Euthanasia and assisted suicide have proved to be very contentious topics in medical ethics. Some ethicists are particularly concerned that allowing physicians to carry out these procedures will undermine their professional obligations and threaten the very goals of medicine. However, I maintain that the fundamental goals of medicine not only do not preclude the practice of euthanasia and assisted suicide by physicians, but can in fact be seen to support these practices in some instances. I look (...) at two influential views of the goals of medicine, one based on the broad guiding principles of autonomy, beneficence and nonmaleficence, and the other focusing on several more concrete aims, concluding that both approaches can be seen to support euthanasia and assisted suicide. I then turn to the popular concern that allowing physicians to carry out euthanasia and assisted suicide will lead to widespread abuse. I argue that the possibility for abuse can be minimised if we make the patient's autonomous consent an essential requirement of the practice. (shrink)

(Pre-publication draft November 2015: Partial content of "Introduction: The 2030 Agenda," Journal of Global Ethics 11:3 [December 2015], 262-270) This introduction briefly explains the process through which the Sustainable Development Goals have developed from their receipt in 2014 to their passage in September 2015 by the UN General Assembly, and it considers their development in prospect. The Millennium Development Goals, which spanned 1990-2015, present a case study that reveals the changeability of such long-term multilateral commitments. They were enmeshed in overlapping (...) and inconsistent national and intergovernmental commitments reaching from 1995 to 2005, and the text of those goals also evolved, stabilizing for the last time in 2007. The Sustainable Development Goals and attendant commitments should be expected to evolve similarly over their fifteen year run. This presents a concern, for among the three committees established by the UN to create the goals, the two committees charged with public consultation were retired as planned in 2014. The process evident thereafter has displayed a shift towards a strategy of enrolling broad public endorsement that leaves such consultation and specific responsibility to those consulted in doubt. This bodes ill for public deliberation on the goals and for public accountability as the agenda proceeds towards 2030. (shrink)

The first section of this paper asks why the notion of consensus has recently come to the fore in the medical humanities, and suggests that the answer is a function of growing technological and professional complexity. The next two sections examine the concept of consensus analytically, citing some of the recent philosophical literature. The fourth section looks at committee deliberations and their desirable outcomes, and questions the degree to which consensus serves those outcomes. In the fifth and last section (...) it is suggested that if I am to subscribe to a consensual outcome responsibly I must be personally committed to it, and that this requires a form of knowledge I call ‘fiduciary’, in this case knowledge of the competence and trustworthiness of other participants in deliberation whose expertise may have influenced my agreement. (shrink)

Healthcare systems need to consider not only how to prevent error, but how to respond to errors when they occur. In the United Kingdom’s National Health Service, one strand of this latter response is the ‘No Blame Culture’, which draws attention from individuals and towards systems in the process of understanding an error. Defences of the No Blame Culture typically fail to distinguish between blaming someone and holding them responsible. This article argues for a ‘responsibility culture’, where healthcare professionals (...) are held responsible in cases of foreseeable and avoidable errors. We demonstrate how healthcare professionals can justifiably be held responsible for their errors even though they work in challenging circumstances. We then review the idea of ‘responsibility without blame’, applying this to cases of error in healthcare. Sensitive to the undesirable effects of blaming healthcare professionals and to the moral significance of holding individuals accountable, we argue that a responsibility culture has significant advantages over a No Blame Culture due to its capacity to enhance patient safety and support medical professionals in learning from their mistakes, while also recognising and validating the legitimate sense of responsibility that many medical professionals feel following avoidable error, and motivating medical professionals to report errors. (shrink)

Steve Clarke, Nathan Emmerich, Francesca Minerva and Toni Saad have offered nuanced and insightful commentaries on my paper ‘The truth behind conscientious objection in medicine’.1 I cannot, in this brief response, do justice to all of the objections and suggestions that they have raised. I have tried to focus my response on what I take to be my interlocutors’ main concerns with my Smithian account, with the hope that we can continue the conversation elsewhere. Clarke argues that both Smith (...) and I ‘underestimate the difficulties involved in overcoming the distorting influence of “self-love” on moral judgement’ and ‘fail to recognise how easy it is for us to mistake a self-interested view for an impartial one’.2 His thought is that cognitive bias and ideological commitments will prevent many of us from identifying the standpoint of the impartial spectator and from realising that we are not impartial.1 I agree that successfully adopting the standpoint of the impartial spectator is not an easy task. However, moral reasoning more generally is difficult and susceptible to bias. This does not mean that we should cease such reasoning; rather, we ought to do our best, and we are, at times, successful. Clarke discusses the entrenched attitudes of Antebellum white racists. However, attitudes about slavery have changed, and cognitive biases can change too. In other words, moral progress is possible. Moreover, as I argue in the paper, one of the advantages of the impartial-spectator approach is that it ‘provides a standpoint from which shared deliberation is possible and public reasons are available’.1 Thus, we can appreciate, with relative ease, whether an objector is reasoning from this standpoint. Clarke further argues that we should entertain the idea of employing ‘experts who are trained to overcome cognitive bias and to set aside ideological commitments’ and …. (shrink)