Originally published in 1999, this classic textbook includes twenty-six cases with commentary and bibliographic resources designed especially for medical students and the training of ethics consultants. The majority of the cases reflect the day-to-day moral struggles within the walls of hospitals typically described as community hospitals; as a result, the cases do not focus on esoteric, high-tech dilemmas--viz., genetic engineering or experimental protocols--but rather on fundamental problems that are pervasive in basic healthcare delivery in the United States: where to send (...) a frail, elderly patient who refuses to go to a nursing home; what role the family should play in making a treatment decision; what a hospital should do when it is getting stuck with too many unpaid bills. This thoroughly revised and updated second edition includes thirteen new cases, five of which are designated as "skill builder" cases aimed specifically for those participants in the Neiswanger Institute for Bioethics' web-based instructional program. This edition has also been restructured for teachability, and will feature reformatted and revised commentaries. (shrink)

Both communitarianism and casuistry have sought to restore ethics as a practical science—the former by incorporating various traditions into a shared definition of the common good, the latter by considering the circumstances of each situation through critical reasoning. Mark G. Kuczewski analyzes the origins and methods of these two approaches and forges from them a new unified approach. This approach takes the communitarian notion of the person as its starting point but also relies upon the narrative and analogical (...) tools of case-based reasoning. He separates out the rhetoric that is incongruent with the Aristotelian aspirations of each method to show that the two are complementary, and that consensus can emerge from fragmentation. He then applies his resulting method to three major problems in bioethics: the difficulties that the issue of personal identity poses for advance directives, the role of the family in medical decision making, and the refusal of treatment because of religious beliefs. He analyzes the need to assume a communitarian notion of the person as a starting point for the application of casuistic insights. Combining theoretical, practical, and scholarly insights, this book will be of interest to philosophers, political and social scientists, and bioethicists. (shrink)

Contemporary bioethics has been somewhat skewed by its focus on high-tech medicine and the resulting development of ethical frameworks based on an acute-care model of healthcare. Research and scholarship in bioethics have payed only cursory attention to ethical issues related to disability. I argue that bioethics should concern itself with the full range of theoretical and practical issues related to disability. This encounter with the disability community will enrich bioethics and, potentially, society as well. I suggest a number of items (...) that the bioethics agenda should include, such as the development of a casuistry of the right to healthcare and to community integration and an advocacy role in fostering an understanding among the public and policy makers of the need to reform research and treatment related to disability. (shrink)

Bioethicists think about families in terms of conflicting interests. This mistake results from an impoverished notion of informed consent. Only by adequately characterizing the process of informed consent can we capture the phenomenon of shared decisionmaking.

I analyze the insights present in Elisabeth Kübler-Ross’s seminal work, On Death and Dying that have laid the foundation for contemporary clinical bioethics as it is practiced by clinical ethics co...

Spirituality or religion often presents as a foreign element to the clinical environment, and its language and reasoning can be a source of conflict there. As a result, the use of spirituality or religion by patients and families seems to be a solicitation that is destined to be unanswered and seems to open a distance between those who speak this language and those who do not. I argue that there are two promising approaches for engaging such language and helping patients (...) and their families to productively engage in the decision-making process. First, patient-centered interviewing techniques can be employed to explore the patient's religious or spiritual beliefs and successfully translate them into choices. Second, and more radically, I suggest that in some more recalcitrant conflicts regarding treatment plans, resolution may require that clinicians become more involved, personally engaging in discussion and disclosure of religious and spiritual worldviews. I believe that both these approaches are supported by rich models of informed consent such as the transparency model and identify considerations and circumstances that can justify such personal disclosures. I conclude by offering some considerations for curbing potential unprofessional excesses or abuses in discussing spirituality and religion with patients. (shrink)

Immigrants lacking health insurance access the health care system through the emergency departments of non-profit hospitals. Because these persons lack health insurance, continued care can pose challenges to those institutions. I analyze the values of our health care institutions, utilizing a Walzerian approach that describes its appropriate sphere of justice. This particular sphere is dominated by a caring response to need. I suggest that the logic of this sphere would be best preserved by providing increased access to health insurance to (...) this population. This access would marry the rights of these members of our community to access care to our responsibility to contribute to financing of the system. I close with some considerations on what it means to be a member of the community. (shrink)

Medicine is in a very self-reflective mood. There is a revival of interest not only in medical ethics but also in medical history, the Hippocratic corpus, and various kinds of literature that indicate physicians are reexamining the foundations of medicine and what it is that gives meaning to medicine. That is, they are reexamining the physician's vocation, in the true sense of vocation as a calling. This interest has coincided with the concern of third parties such as accreditation agencies about (...) the professionalism of physicians. (shrink)

I explore the possible meanings that the notion of the common morality can have in a contemporary communitarian approach to ethics and public policy. The common morality can be defined as the conditions for shared pursuit of the good or as the values, deliberations, traditions, and common construction of the narrative of a people. The former sense sees the common morality as the universal and invariant structures of morality while the second sense is much more contingent in nature. Nevertheless, the (...) communitarian sees both aspects as integral in devising solutions to public policy problems. I outline how both meanings follow from communitarian philosophical anthropology and illustrate how they work together when addressing a question such as that of providing universal health insurance in the United States. The common morality forms the basis of building an implicit consensus that is available to and reaffirmed by the shared reflections of the citizenry. (shrink)

ABSTRACTI consider objections to the use of living wills based upon the discontinuity of personal identity between the time of the execution of the directive anbd the time the person becomes incompetent. Recent authors, following Derek Parfit's “Complex View” of personal identity, have argued that there is often not sufficient identity interests between the competent person who executes the living will and the incompetent patient to warrant the use of the advance directive. I argue that such critics err by seeking (...) personal identity in a purely descriptive manner. By exploring Buchanan and Brock's concept of “surviving interests”, an argument is developed that certain future‐oriented acts have a normative force that contributes to the narrative unity which is constitutive of personal ideality. This narrative concept of the self is entailed by many of the our ordinary practices and challenges the philosophical consensus to view the self in a more dynamic and communitarian manner. (shrink)

I consider the problem liberalism poses for bioethics.Liberalism is a view that advocates that the state remain neutralto views of the good life. This view is sometimes supported by askeptical moral epistemology that tends to propel liberalismtoward libertarianism. I argue that the possibilities for sharedagreement on moral matters are more promising than is sometimesappreciated by such a view of liberalism. Using two examples ofpublic debates of moral issues, I show that commonly sharedintuitions may ground moral principles even if they may (...) be givendifferent weight by persons of different moral and religioustraditions. Nevertheless, the fact that the intuition andprinciple is widely shared may be sufficient to chart somedirections for public policy or cooperative action even if theydo not lead to complete agreement. As a result, I argue that aliberal communitarianism that presupposes a fairly minimalistepistemology is a legitimate approach to achieving sharedagreement in a pluralistic society. (shrink)

Communitarian critics have derided case-based reasoning for ignoring the need to arrive at a shared hierarchy of goods prior to case.

It has become common in medical ethics to discuss difficult cases in terms of the principles of respect for autonomy, beneficence, nonmaleficence, and justice. These moral concepts or principles serve as maxims that are suggestive of appropriate clinical behavior. Because this language evolved primarily in the acute care setting, I consider whether it is in need of supplementation in order to be useful in the long-term care setting. Through analysis of two typical cases involving residents of long-term care facilities, I (...) argue for the additional principles of candor and responsibility for narrative integrity. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Kennedy Institute of Ethics Journal 10.4 (2000) 283-286 [Access article in PDF] Introduction This Issue of the Kennedy Institute of Ethics Journal focuses on "Aristotelianism in Contemporary Bioethics." It is an unusual topic for this journal as it is seemingly very theoretical. But, I assure the reader that the theoretical topics explored are of the most practical and pressing kind. The questions addressed concern what kind of knowledge and (...) skill there can be in deliberating about particular cases and issues, whether this knowledge is culturally relative, and how bioethics can balance the rights of the individual in making health care decisions with responsibilities to the community.Authors in bioethics, especially those working in clinical ethics, have long sought to address particular problems with the fewest theoretical commitments possible so as to make broad consensus more plausible. Since theoretical foundations are often disputed, keeping the discussion pragmatic has seemed the more likely road to agreement. Similarly, our American heritage has lent the rhetoric of the rights of the individual to the scholarly dialogue in bioethics. Although no one wishes to do away with such language completely, it sometimes has seemed inadequate to the moral phenomena. To address these concerns, the philosophy of Aristotle has been recruited. Aristotelianism in contemporary bioethics has become identified with two claims: (1) there is such a thing as the ability to reason wisely about particular problems and cases, and (2) there is a need to supplement the American emphasis on the individual with a richer notion of the person or a concept of the common good. Both of these claims address concerns arising from the doctrine of informed consent, the fundamental framework of medical decision making.Contemporary American biomedical ethics is now more than 25 years old. It has been marked by some important successes. For instance, it has evolved an ethical and legal consensus that the doctrine of informed consent is the primary way to make operational the value of respect for the patient. And this doctrine extends to all areas of medical treatment and biomedical research. The doctrine is minimalist in that it relies simply on [End Page 283] the right of a competent patient to refuse unwanted interventions. This approach naturally raises questions concerning whether it can adequately settle the more difficult moral questions society faces without recourse to a grander philosophical theory. Similarly, the doctrine of informed consent places the rights of the individual front and center, and this causes us to ask whether bioethics is intrinsically individualistic. Although some might find individualism unobjectionable, many claim that such individualism does not capture the moral phenomenon of the family's role in ethical medical decision making (Nelson and Nelson 1995) or the need to see particular choices in light of the health care schema we wish for society (Callahan 1990).Aristotelianism has not presented itself as just another competing theory among other approaches to bioethics. Through the notions of practical wisdom and the common good, Aristotelianism can be seen as a metaethical way of tying together the methodological progress in bioethics that has resulted from a rich debate among various methods. For instance, bioethics has seen the flourishing of two important methods: the principles approach and casuistry. Virtue theory has also received much attention. The representatives of each have often argued that the philosophical concepts and principles behind ethical decision making in medicine are minimal.Whether one is talking about the four principles approach of Beauchamp and Childress (1994), the case-based approach (casuistry) of Jonsen and Toulmin (1988), or the virtue theory of Pellegrino and Thomasma (1993), one immediately notices that each method is fairly dependent on the judgment or practical wisdom of a competent practitioner of the method in order to be effective. The four principles approach depends upon someone being able to balance or to specify its mid-level principles in difficult cases; casuistry requires the discrimination of a person of practical wisdom to identify relevant features of cases and reason analogically between paradigm cases and their less clear particular instances, and virtue theory places the competent practitioner of the clinical art at the center of its method and makes... (shrink)

The patient was born at 29 weeks gestation. There was a prenatal diagnosis that the child's small intestine had developed outside of the abdominal cavity. The length of gestation had made the initial prognosis good. But after birth, surgery to place the intestine back into the abdominal cavity found that the baby actually had very little small intestine and a diagnosis of was made. The amount of small intestine was not compatible with survival. The transplant service saw the baby twice (...) and each time said the baby's profile did not meet the transplant protocol. (shrink)

The debate regarding physician-assisted suicide continues in our society. Despite the recent opinions of the United States Supreme Court, this issue is unlikely to go away anytime soon. For a variety of reasons, this debate is now conducted in the legalistic terms of individual rights and liberties. As a result, perhaps we philosophers have been left behind. This is now a matter for the legal arena and philosophy is likely to be irrelevant. I would like to suggest otherwise for two (...) reasons. (shrink)

The patient was a 19-year-old female who was transferred to this children's hospital from a community hospital in a neighboring state. She is well known to the hospital staff because she had a kidney transplanted and retransplanted several times there. Her first transplant as at age 8 and she was retransplanted most recently approximately 3 years ago. She immediately rejected her second kidney and received a third. She is currently admitted because she is again rejecting her kidney, probably due to (...) not taking her medication. The ethics consultant was called because the attending physician wanted to know if it was ethical to retransplant a patient. (shrink)

This special section deals with the new professionalism movement. The interest in the term “professionalism” has been growing steadily in medicine, and the word now seems to be everywhere. However, bioethicists have lagged behind our colleagues in medicine and nursing in explicitly contributing to this movement. This special section adds to the effort to catch up.

A 24-year-old Hispanic male came into the emergency room of a large public teaching hospital with acute cardiac failure and chest pain. He was admitted and diagnosed with rheumatic heart disease and regurgitation and stenosis of both mitral and aortic valves. Medical judgment concluded that the patient needed to be medically stabilized and then undergo cardiac surgery to repair heart valves. The patient spoke only Spanish. Investigation through an interpreter revealed that he was an illegal alien from a Central American (...) country who has lived in this country for five to seven years. He came to the United States so that he could receive treatment for his heart condition, evidently fearing that he would not receive treatment in his home country. The patient entered this country through the assistance of some distant relatives. He did not have a strong support system. (shrink)

The transplant coordinator scheduled a meeting that included numerous members of the multidisciplinary team, among them the transplant surgeon, a social worker, a psychologist, and an ethics consultant. The ethics consultant outlined the ethical issues and made a recommendation. The consultant argued that the question whether the patient should again be listed as a transplant candidate really came down to the kind of environment that could be provided during aftercare. That is, if a rather structured living environmentcould be found for (...) the patient, then retransplantation might be warranted. But without such an environment, the patient would again probably fail to adhere to the medical and psychological treatment regimen necessary for a successful life as a transplant recipient. The psychologist, who had been working closely with the ethics consultant, concurred in this opinion. (shrink)

Contemporary bioethicists and scholars of ancient philosophy explore the import of classical ethics on pressing bioethical concerns.

This collection of thirty-one cases and commentaries addresses ethical problems commonly encountered by the average health care professional, not just those working on such high-tech specialties as organ transplants or genetic engineering. It deals with familiar issues that are rarely considered in ethics casebooks, including such fundamental matters as informed consent, patient decision-making capacity, the role of the family, and end-of-life decisions. It also provides resources for basic but neglected ethical issues involving placement decisions for elderly or technologically dependent patients, (...) rehabilitation care, confidentiality regarding AIDS, professional responsibility, and organizational and institutional ethics. The authors describe in detail the perspectives of each party to the case, the kind of language that ethicists use to discuss the issues, and the outcome of the case. A short bibliography suggests useful articles for further reading or curriculum development. Easily understood by readers with no prior training in ethics, this book offers guidance on everyday problems from across the broad continuum of care. It will be valuable for health-care professionals, hospital ethics committees, and for students preparing for careers in health-care professions. (shrink)

The topic of developing professionalism dominated the content of many academic medicine publications and conference agendas during the past decade. Calls to address the development of professionalism among medical students and residents have come from professional societies, accrediting agencies, and a host of educators in the biomedical sciences. The language of the professionalism movement is now a given among those in academic medicine. We raise serious concerns about the professionalism discourse and how the specialized language of academic medicine disciplines has (...) defined, organized, contained, and made seemingly immutable a group of attitudes, values, and behaviors subsumed under the label of "professionalism." In particular, we argue that the professionalism discourse needs to pay more attention to the academic environment in which students are educated, that it should articulate specific positive behaviors, that the theory of professionalism must be constructed from a dialogue with those we are educating, and that this theoretical and practical discourse must aim at a deeper understanding of social justice and the role of medicine within a just society. (shrink)

In October 2012, the Loyola University Chicago Stritch School of Medicine amended its eligibility requirements for admission. In addition to U.S. citizens and permanent residents, persons who qualify for the Deferred Action for Childhood Arrivals program of the United States Citizenship and Immigration Service are now eligible for admission. Simply put, we extended the educational opportunity of medical school to people who are in a particular category of undocumented immigrants. We became the first medical school in the United States to (...) have an intentional, transparent policy of eligibility for persons eligible for the DACA program. This expanded admissions policy has gained some attention in the popular press and brought us many expressions of support. It has also dismayed a few members of our school's circle of faculty and alumni.We wish to walk you through the history of our policy's development. We believe that viewing it as it developed will make clear three pertinent ideas: this policy flows directly from the mission of medical schools, it suits a positive notion of social justice and is also compelled by a duty not to discriminate on arbitrary grounds, and educators who steward educational institutions must have the moral courage to place considerations of institutional mission and social justice above the political views and negative responses of some alumni and donors. (shrink)

The American Journal of Bioethics, Volume 11, Issue 12, Page 1-3, December 2011.

This dissertation examines the two most popular contemporary revivals of Aristotelian ethics, communitarianism and casuistry. I consider how these two schools of thought which take Aristotle's ethics as their starting point, can seem to be so diametrically opposed. The communitarian approach to ethics, personified by Alasdair MacIntyre, Michael Sandel, and Ezekiel J. Emanuel argues that a shared notion of the self or the good life must be sought prior to resolving ethical problems. Conversely, the new casuistic movement, exemplified by the (...) recent work of Albert Jonsen, Stephen Toulmin, and Carson Strong eschews such theoretical baggage in favor of a case-based ethics. By examining each school of thought in the light of their Aristotelian aspirations, namely, their desire to re-establish an ethics based upon prudence that overcomes the fact/value distinction, spurious elements of their rhetoric are rejected. This allows us to see the compatible strains in communitarianism and casuistry and to demonstrate the elements they must borrow from each other in order to be viable approaches to ethical and political philosophy. (shrink)

The ethics consultant attended two of the weekly nursing conferences on this unit to process the feelings that the nurses expressed about the case, to explain the kind of ethical reasoning that has evolved regarding the forgoing of life-sustaining treatment, and to acknowledge some things he could have done better. In particular, this consultant came to believe that he had made a mistake in inferring that his job was only to provide the information to the attending physician that was requested. (...) This physician had suggested that he would prefer to deal directly with the family and only needed information from the consultant. Although the physician continually held open the possibility that at some time in the near future he might ask the consultant to meet with the family, that request never came despite repeated offers of assistance. (shrink)

The Code of Ethics for Health Care Ethics Consultation (HCEC) is a pivotal step in the process of identifying and clarifying standards in our field. It draws on the Core Competencies articulated by...

The American Journal of Bioethics, Volume 12, Issue 3, Page 40-42, March 2012.

Clinical ethics consultation is largely outside the scope of regulation and oversight, despite its importance. For decades, the bioethics community has been unable to reach a consensus on whether there should be accountability in this work, as there is for other clinical activities that influence the care of patients. The American Society for Bioethics and Humanities, the primary society of bioethicists and scholars in the medical humanities and the organizational home for individuals who perform CEC in the United States, has (...) initiated a two‐step quality attestation process as a means to assess clinical ethics consultants and help identify individuals who are qualified to perform this role. This article describes the process. (shrink)

The field of clinical ethics consultation has matured into a multidisciplinary profession, with clinical ethics consultants (CECs) being trained in bioethics, philosophy, theology, law, medicine, n...

Reflection in medical education is becoming more widespread. Drawing on our Jesuit Catholic heritage, the Loyola University Chicago Stritch School of Medicine incorporates reflection in its formal curriculum and co–curricular programs. The aim of this type of reflection is to help students in their formation as they learn to step back and analyze their experiences in medical education and their impact on the student. Although reflection is incorporated through all four years of our undergraduate medical curriculum, this essay will focus (...) on three areas where bioethics faculty and medical educators have purposefully integrated reflection in the medical school, specifically within our bioethics education and professional development efforts: 1) in our three–year longitudinal clinical skills course Patient Centered Medicine (PCM), 2) in our co–curricular Bioethics and Professionalism Honors Program, and 3) in our newly created Physician’s Vocation Program (PVP). (shrink)

This paper describes the first three-year experience of the Consortium Ethics Program (CEP-1) of the University of Pittsburgh Center for Medical Ethics, and also outlines plans for the second three-year phase (CEP-2) of this experiment in continuing ethics education. In existence since 1990, the CEP has the primary goal of creating a cost-effective, permanent ethics resource network, by utilizing the educational resources of a university bioethics center and the practical expertise of a regional hospital council. The CEP's conception and specific (...) components stem from recognition of the need to make each hospital a major focus of educational efforts, and to provide academic support for the in-house activities of the representatives from each institution. (shrink)