As in science, so in bioethics: if prohibiting conflicts of interest is not feasible, rigorous requirements for disclosure can at least manage them.

Carol Gilligan has identified two orientations to moral understanding; the dominant justice orientation and the under-valued care orientation. Based on her discernment of a voice of care, Gilligan challenges the adequacy of a deontological liberal framework for moral development and moral theory. This paper examines how the orientations of justice and care are played out in medical ethical theory. Specifically, I question whether the medical moral domain is adequately described by the norms of impartiality, universality, and equality that characterize the (...) liberal ideal. My analysis of justice -oriented medical ethics, focuses on the libertarian theory of H.T. Engelhardt and the contractarian theory of R.M. Veatch. I suggest that in the work of E.D. Pellegrino and D.C. Thomasma we find not only a more authentic representation of medical morality but also a project that is compatible with the care orientation's emphasis on human need and responsiveness to particular others. (shrink)

Edmund Pellegrino has argued that the dramatic changes in American health care call for critical reflection on the traditional norms governing the therapeutic relationship. This paper offers such reflection on the obligation to do no harm. Drawing on work by Beauchamp and Childress and Pellegrino and Thomasma, I argue that the libertarian model of medical ethics offered by Engelhardt cannot adequately sustain an obligation to do no harm. Because the obligation to do no harm is not based simply on a (...) negative duty of nonmaleficence but also on a positive duty of beneficence, I argue that it is best understood to derive from the fiduciary nature of the healing relationship. (shrink)

In this paper, I examine the notion of accountability and its historical evolution in health care. Using medical mistakes and adverse patient outcomes as my focus, I examine the interests served by particular models of accountability and argue for a model of collective fiduciary responsibility in U.S. health care today.

: The terms "appropriate" and "necessary" are crucial determinants in decisions regarding the use and reimbursement of medical treatments. This paper encourages greater awareness of the political, economic, and normative assumptions that give meaning to these concepts.

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