Research to improve the health of pregnant and fetal patients presents ethical challenges to clinical investigators, institutional review boards, funding agencies, and data safety and monitoring boards. The Common Rule sets out requirements that such research must satisfy but no ethical framework to guide their application. We provide such an ethical framework, based on the ethical concept of the fetus as a patient. We offer criteria for innovation and for Phase I and II and then for Phase III clinical trials (...) to improve the health of pregnant patients and of fetal patients and also criteria to responsibly manage the transition from investigation to clinical practice. Basing ethical criteria for research involving pregnant women on the ethical concept of the fetus as a patient insulates the proposed ethical framework and therefore research on pregnant women from the divisive and politicized concepts and discourses of personhood, fetal rights, and unborn child. (shrink)

Physicians may justifiably limit patients' refusals of medical interventions when the refusal is based on a negative right to noninterference coupled with a request for an unreasonable alternative.

The American Journal of Bioethics, Volume 11, Issue 12, Page 59-61, December 2011.

The American Journal of Bioethics, Volume 12, Issue 7, Page 1-2, July 2012.

Research to improve the health of pregnant and fetal patients presents ethical challenges to clinical investigators, institutional review boards, funding agencies, and data safety and monitoring boards. The Common Rule sets out requirements that such research must satisfy but no ethical framework to guide their application. We provide such an ethical framework, based on the ethical concept of the fetus as a patient. We offer criteria for innovation and for Phase I and II and then for Phase III clinical trials (...) to improve the health of pregnant patients and of fetal patients and also criteria to responsibly manage the transition from investigation to clinical practice. Basing ethical criteria for research involving pregnant women on the ethical concept of the fetus as a patient insulates the proposed ethical framework and therefore research on pregnant women from the divisive and politicized concepts and discourses of personhood, fetal rights, and unborn child. (shrink)

The ethics of managing obstetric patients in medical disasters poses ethical challenges that are unique in comparison to other disaster patients, because the medical needs of two patients—the pregnant patient and the fetal patient—must be considered. We provide an ethical framework for doing so. We base the framework on the justice-based prevention of exploitation of populations of patients, both obstetric and non-obstetric, in medical disasters. We use the concept of exploitation to identify a spectrum from ethically acceptable, to ethically challenging, (...) to ethically unacceptable, management of obstetric patients in medical disasters. We also address the ethics of the care of obstetric and neonatal patients when the resources of a hospital are completely overwhelmed in a large-scale medical disaster. (shrink)

Despite its prominence in the abortion debate and in public policy, the discourse of 'unborn patient' has not been subjected to critical scrutiny. We provide a critical analysis in three steps. First, we distinguish between the descriptive and normative meanings of 'unborn child.' There is a long history of the descriptive use of 'unborn child.' Second, we argue that the concept of an unborn child has normative content but that this content does not do the work that opponents of abortion (...) want it to do, namely, to establish the independent moral status of fetuses and their rights, the right to life in particular. Third, we argue that the normative content of 'unborn child' should be dependent moral status, not independent moral status. We conclude that the ethical concept of the fetus as a patient should replace the discourse of “unborn child” when that phrase is used normatively. (shrink)

Despite its prominence in the abortion debate and in public policy, the discourse of ‘unborn patient’ has not been subjected to critical scrutiny. We provide a critical analysis in three steps. First, we distinguish between the descriptive and normative meanings of ‘unborn child.’ There is a long history of the descriptive use of ‘unborn child.’ Second, we argue that the concept of an unborn child has normative content but that this content does not do the work that opponents of abortion (...) want it to do, namely, to establish the independent moral status of fetuses and their rights, the right to life in particular. Third, we argue that the normative content of ‘unborn child’ should be dependent moral status, not independent moral status. We conclude that the ethical concept of the fetus as a patient should replace the discourse of “unborn child” when that phrase is used normatively. (shrink)

The clinical ethics literature is striking for the absence of an important genre of scholarship that is common to the literature of clinical medicine: systematic reviews. As a consequence, the field of clinical ethics lacks the internal, corrective effect of review articles that are designed to reduce potential bias. This article inaugurates a new section of the annual "Clinical Ethics" issue of the Journal of Medicine and Philosophy on systematic reviews. Using recently articulated standards for argument-based normative ethics, we provide (...) a systematic review of the literature on concealed medication for the management of psychiatric disorders. Four steps are completed: identify a focused question; conduct a literature search using key terms relevant to the focused question; assess the adequacy of the argument-based methods of the papers identified; and identify conclusions drawn in each paper and whether they apply to the focused question. We identified seven papers and provide an assessment of them. While none of the papers fully meet the standards of argument-based ethics, they did provide rationales for the use of concealed medications, with the important requirement such a practice be accountable in explicit organizational policy to prevent abuse of patients with mental illness or dementia. (shrink)

Incivility among physicians, between physicians and learners, and between physicians and nurses or other healthcare professionals has become commonplace. If allowed to continue unchecked by academic leaders and medical educators, incivility can cause personal psychological injury and seriously damage organisational culture. As such, incivility is a potent threat to professionalism. This paper uniquely draws on the history of professional ethics in medicine to provide a historically based, philosophical account of the professional virtue of civility. We use a two-step method of (...) ethical reasoning, namely ethical analysis informed by pertinent prior work, followed by identifying the implications of clearly articulated ethical concepts, to meet these goals. The professional virtue of civility and the related concept of professional etiquette was first described by the English physician-ethicist Thomas Percival (1740–1804). Based on a historically informed philosophical account, we propose that the professional virtue of civility has cognitive, affective, behavioural and social components based on a commitment to excellence in scientific and clinical reasoning. Its practice prevents a dysfunctional organisational culture of incivility and sustains a civility-based organisational culture of professionalism. Medical educators and academic leaders are in a pivotal and powerful position to role model, promote and inculcate the professional virtue of civility as essential to an organisational culture of professionalism. Academic leaders should hold medical educators accountable for discharge of this indispensable professional responsibility. (shrink)

On February 3, 2010, a “Letter of Concern from Bioethicists,” organized by fetaldex.org, was sent to report suspected violations of the ethics of human subjects research in the off-label use of dexamethasone during pregnancy by Dr. Maria New. Copies of this letter were submitted to the FDA Office of Pediatric Therapeutics, the Department of Health and Human Services (DHHS) Office for Human Research Protections, and three universities where Dr. New has held or holds appointments. We provide a critical appraisal of (...) the Letter of Concern and show that it makes false claims, misrepresents scientific publications and websites, fails to meet standards of evidence-based reasoning, makes undocumented claims, treats as settled matters what are, instead, ongoing controversies, offers “mere opinion” as a substitute for argument, and makes contradictory claims. The Letter of Concern is a case study in unethical transgressive bioethics. We call on fetaldex.org to withdraw the letter and for co-signatories to withdraw their approval of it. (shrink)

Background: Treatment of psychotic disorders in pregnancy is often ethically and clinically challenging, especially when psychotic symptoms impair decision-making capacity. There are several competing ethical obligations to consider: the ethical obligation to maternal autonomy, the maternal and fetal beneficence-based obligations to treat peripartum psychosis, and the fetal beneficence-based obligation to minimize teratogenic exposure. Objective: This article outlines an ethical framework for clinical decision-making for the management of chronic psychosis in pregnancy, with an emphasis on special considerations in the previable and (...) periviable period. Case Presentation: A 31-year-old gravida 2, para 1 with intrauterine pregnancy at 12 weeks and 4 days gestation was brought to the emergency department by her husband seven months after delivering her first child, due to sudden onset of behavioral changes that included self-isolation, not eating, and not taking care of her child. Her past medical history included hypothyroidism and inflammatory bowel disease, but no prior psychiatric illness. After being admitted to the psychiatric hospital, she continued to have poor oral intake and weight loss despite initial inpatient treatment with antipsychotics, levothyroxine, and discontinuation of corticosteroids. Her pregnancy was also complicated by the diagnosis of multiple fetal anomalies at 20 weeks gestation, when the fetus was periviable. Conclusions: For previable or periviable pregnancies, the patient and/or surrogate should decide whether to pursue prenatal genetic screening and invasive diagnostic testing, as well as whether to continue or terminate the pregnancy. When the choice is made to continue the pregnancy, initiation of long-term psychiatric treatment (including medications with potential adverse fetal effects) should be based on shared decision-making between the physician and the patient and/or surrogate. Although some pharmacologic interventions may have potential adverse effects on the developing fetus, the use of psychotropic medications can be ethically justified, even if the patient herself does not have the capacity to consent and requires a surrogate, when the goal is to restore maternal autonomy and minimize the risks of maternal and fetal harm from untreated psychiatric illness. (shrink)

Book reviewed in this article: Ethics in Obstetrics and Gynecology. By Laurence B. McCullough and Frank A. Chervenak.

On February 3, 2010, a “Letter of Concern from Bioethicists,” organized by fetaldex.org, was sent to report suspected violations of the ethics of human subjects research in the off-label use of dexamethasone during pregnancy by Dr. Maria New. Copies of this letter were submitted to the FDA Office of Pediatric Therapeutics, the Department of Health and Human Services Office for Human Research Protections, and three universities where Dr. New has held or holds appointments. We provide a critical appraisal of the (...) Letter of Concern and show that it makes false claims, misrepresents scientific publications and websites, fails to meet standards of evidence-based reasoning, makes undocumented claims, treats as settled matters what are, instead, ongoing controversies, offers “mere opinion” as a substitute for argument, and makes contradictory claims. The Letter of Concern is a case study in unethical transgressive bioethics. We call on fetaldex.org to withdraw the letter and for co-signatories to withdraw their approval of it. (shrink)

In our ‘The Professional Virtue of Civility and the Responsibilities of Medical Educators and Academic Leaders’,1 we provided an historically based conceptual account of the professional virtue of civility and the role of leaders of academic health centres in creating and sustaining an organisational culture of professionalism that promotes civility among healthcare professionals and between medical educators and learners. We emphasised that any adequate understanding of the virtues, including professional virtues, has cognitive, affective, behavioural and social components. Some of the (...) commentators expand on these components in important ways. Xuhao et al emphasises the importance of role models, especially in the hierarchical context of medical education.2 The hierarchy of faculty in the senior position and junior doctors and other learners below them has characterised medical education for centuries. Xuhao et al rightly call for academic leaders to shape this hierarchy in a morally responsible way, by becoming ‘exemplary role models’.2 Berry, a clinician manager, in critiquing our account, calls for an increased appreciation for the psychological and environmental factors that might explain why uncivil behaviour occurs.3 …. (shrink)

Heuser, Eller and Byrne provide important descriptive ethics data about how physicians counsel women on the clinical management of pregnancies complicated by severe fetal anomalies. The authors present an account of what such counselling ought to be based on, the ethical concept of the fetus as a patient and the professional responsibility model of obstetric ethics. When there is certainty about the diagnosis and either a very high probability of either death as the outcome of the anomaly or survival with (...) severe and irreversible deficit of cognitive developmental capacity as a result of the anomaly diagnosed, the pregnant woman should be offered the alternatives of aggressive and non-aggressive obstetric management and induced abortion before viability. It is also ethically permissible to offer feticide followed by termination of pregnancy after viability in such cases. This ethically justified approach will reduce the variation in the actual practices of specialists in maternal–fetal medicine described by Heuser, Eller and Byrne. (shrink)

This book takes up the central themes of Aristotle's metaphysical theory and the various transformations they undergo prior to their full expression in the Metaphysics. Aristotle's metaphysics is bedevilled by classic puzzles involving such notions as form, predication, universal, and substance, which result from his attempt to adapt the various requirements on primary substance developed in his earlier works so that they fit the very different metaphysical picture in his later work. Professor Lewis argues that Aristotle is himself aware of (...) most if not all of these difficulties and in the Metaphysics works hard to ensure the coherence of his theory. He presents Aristotle's views as a formal theory complete with axioms, definitions, and theorems. (shrink)

Frank A. Lewis presents a close study of book Zeta of Aristotle's Metaphysics, one of his most dense and controversial texts, commonly understood to contain his deepest thoughts on the definition of substance and related metaphysical issues. Lewis argues that Aristotle returns to the causal view of primary substance from his Posterior Analytics.

Secular change in sex ratios is examined in relation to experience in the family. Two theoretical perspectives are outlined: Guttentag and Secord’s (1983) adaptation of social exchange theory, and sexual selection theory. Because of large-scale change in number of births and typical age differentials between men and women at marriage, low sex ratios at couple formation ages existed in the U.S. between 1965 and the early 1980s. The currently high sex ratios, however, will persist until the end of the century. (...) High sex ratios appear to be associated with lower divorce rates, male commitment to careers that promise economic rewards, male willingness to engage in child care, higher fertility, and higher rates of sexual violence. Sexual selection theory calls attention to intrasexual competition in the numerically larger sex. (shrink)

ABSTARCT When people go shopping, they enter a building. But the shop cannot be identified with the building, because it would remain the same shop if it moved to another building or if it became an e-store. Daniel Korman [2019] uses these two observations to argue that establishments are immaterial objects. However, all that follows is that establishments are not buildings. I argue that establishments are organisations or corporate agents that are constituted by people. This entails that they are material (...) objects. Korman’s observations can be accommodated in terms of the further observation that corporate agents can but need not own or rent buildings. (shrink)

ABSTARCT When people go shopping, they enter a building. But the shop cannot be identified with the building, because it would remain the same shop if it moved to another building or if it became an e-store. Daniel Korman [2019] uses these two observations to argue that establishments are immaterial objects. However, all that follows is that establishments are not buildings. I argue that establishments are organisations or corporate agents that are constituted by people. This entails that they are material (...) objects. Korman’s observations can be accommodated in terms of the further observation that corporate agents can but need not own or rent buildings. (shrink)

A modest solution to the problem(s) of rule-following is defended against Kripkensteinian scepticism about meaning. Even though parts of it generalise to other concepts, the theory as a whole applies to response-dependent concepts only. It is argued that the finiteness problem is not nearly as pressing for such concepts as it may be for some other kinds of concepts. Furthermore, the modest theory uses a notion of justification as sensitivity to countervailing conditions in order to solve the justification problem. Finally, (...) in order to solve the normativity problem, it relies on substantial specifications of normal conditions such as those that have been proposed by Crispin Wright and Mark Johnston, rather than on Philip Pettit's functionalist specification. This theory is modest in that it does not meet the demands of Kripke's sceptic in full. Arguments are provided as to why this is not needed. (shrink)

The topic of homonymy, especially the variety of homonymy that has gone under the title, “focal meaning,” is of fundamental importance to large portions of Aristotle’s work-not to mention its central place in the ongoing controversies between Aristotle and Plato. It is quite astonishing, therefore, that the topic should have gone so long without a book-length treatment. And it is all the more gratifying that the new book on homonymy by Christopher Shields should be so comprehensive, and of such uniformly (...) high quality.’ Everyone who cares about Aristotle will be in his debt. Shields’s book falls into two parts. In the first, he is concerned to lay out the basic structure of Aristotle’s views about homonymy; in the second part, we are led through the various applications of the idea, to the analysis of friendship, for example, the homonymy of the body, the account of goodness and, not least, the homonymy of being. Shields’s book brings out well how the topic of homonymy weaves in and out of the fabric of Aristotle’s thinking in a variety of areas. I will resist the temptation to follow Shields through these various subject-matters, and instead take up essentially two topics. First, (I), the basic outline of Aristotle’s notion of homonymy, more or less independently of its different applications (here, I follow Shields’s example in the first half of his book). Thereafter, I discuss a single application: the homonymy of being (this is the subject of Shields’s last and longest chapter). Here, I will be interested (II) in how homonymy relates to the theory of the categories; and (III) in the application of homonymy to the analysis of substance in the Metaphysics. (shrink)

What in Aristotle corresponds, in whole or (more likely) in part, to our contemporary notion of predication? This paper sketches counterparts in Aristotle's text to our theories of expression and of truth, and on this basis inquires into his treatment of sentences assigning an individual to its kinds. In some recent accounts, the Metaphysics offers a fresh look at such sentences in terms of matter and form, in contrast to the simpler theory on offer in the Categories . I argue (...) that the Metaphysics initiates no change in this regard over the Categories . The point that form is (metaphysically) predicated of matter is a contribution, not to the account of statement predication, but to the analysis of compound material substances. Otherwise put, in our terms Aristotelian form is not - in particular, is not also - a propositional function, but a function from matter to compound material substances. (shrink)

The topic of homonymy, especially the variety of homonymy that has gone under the title, “focal meaning,” is of fundamental importance to large portions of Aristotle’s work—not to mention its central place in the ongoing controversies between Aristotle and Plato. It is quite astonishing, therefore, that the topic should have gone so long without a book-length treatment. And it is all the more gratifying that the new book on homonymy by Christopher Shields should be so comprehensive, and of such uniformly (...) high quality. Everyone who cares about Aristotle will be in his debt. (shrink)

Neither Johnston's nor Wright's account of response-dependence offers a complete picture of response-dependence, as they do not apply to all concepts that are intrinsically related to our mental responses. In order to (begin to) remedy this situation, a new conception of response-dependence is introduced that I call "acceptance-dependence". This account applies to concepts such as goal, constitutional, and money, the first two of which have mistakenly been taken to be response-dependent in another sense. Whereas on Johnston's and Wright's accounts response-dependent (...) concepts depend on counterfactual responses of individuals, acceptance-dependent concepts depend on the actual responses of groups of people. This implies that concepts of the latter kind are less objective than concepts of the former kind. (shrink)

Replying to Theaetetus’ suggestion that knowledge is true opinion at Tht. 200e, Socrates remarks that ‘a whole profession’ testifies against this definition. The orator practises the art of persuasion, not to teach people, but make them believe whatever he wants. If a robbery has taken place, for example, he cannot in a short time teach adequately the truth about what happened to people who were not on the scene.

In this paper, I attempt to set out some of the main views about essence which Aristotle puts forward in Book Z of theMetaphysics.A central feature of Aristotle's account, as we shall see, is his distinction between primary and secondary cases of essence, and a similiar distinction in connection with the related notions of substance and definition. This division between primary and secondary cases means that Aristotle may well have two very different sorts of remark to make about essence, or (...) definition, or substance, according to which of the two kinds of case he has in mind. There is no reason to suppose the same logical properties apply to both the primary and the secondary cases. And when we come to define the various notions, we shall see that if our definitions are right, the logical properties in the two kinds of case are in fact quite different. (shrink)

This article seeks to broaden the debate on the recruitment of REC lay members by arguing that the recruitment of good members requires that there is initially a need to heighten awareness among potential candidates of the nature of the lay contribution. The article offers a recruiting process model of: awareness; advocacy; characterization; recruitment, and training, and focuses on the first three steps in that process. The current position is that there is sparse awareness and advocacy of the role of (...) the lay member at a time of rapid change, both in the ‘research ethics service’ and the lay contribution thereto. Thus it is seen as imperative that positive steps are taken to change this position, filling a lacuna that appears to exist. Given that the candidate pool can become larger and have a fuller understanding of the ‘research ethics service’, better recruitment and hence better-trained members should result. As a way forward, practical ways and means to do this are suggested, providing topics that will engender a wider debate and perhaps as an outcome, some new initiative. (shrink)