Among the important functions of the healthcare provider in providing quality care is the monitoring of the social environment of the patient. Although it is increasingly recognized that caring activity must include the whole patient and not merely the technical and pharmacological aspects of the patient's needs, the impact of the social environment upon the total health state has not been explored and debated to the extent that It might be.

About 1000 references to books, journal articles, government publications, reports, and bibliographies. Topical arrangement under headings such as History of medical ethics, Behavior control, and Truth-telling in medicine. Entries include bibliographical information and occasional brief annotations. Author index.

Assesses the ethical problems that doctors face every day and advocates a more universal code of medical ethics, one that draws on the traditions of religion and philosophy.

In celebration of the fortieth anniversary of the publication of Beauchamp and Childress’s Principles of Biomedical Ethics, a review is undertaken to compare the lists of principles in various bioethical theories to determine the extent to which the various lists can be reconciled. Included are the single principle theories of utilitarianism, libertarianism, Hippocratism, and the theories of Pellegrino, Engelhardt, The Belmont Report, Beauchamp and Childress, Ross, Veatch, and Gert. We find theories all offering lists of principles numbering from one (...) to ten. Many of the differences can be reconciled, but some critical differences remain. (shrink)

No one really believes that literally all functions of the entire brain must be lost for an individual to be dead. A better definition of death involves a higher brain orientation.

Clinicians cannot obtain valid consent to treatment because they cannot guess which treatment option will serve a particular patient's best interests. These guesses could be made more accurately if patients were paired with providers who share their deep values.

When a new, brain-based definition of death was proposed fifty years ago, no one realized that the issue would remain unresolved for so long. Recently, six new controversies have added to the debate: whether there is a right to refuse apnea testing, which set of criteria should be chosen to measure the death of the brain, how the problem of erroneous testing should be handled, whether any of the current criteria sets accurately measures the death of the brain, whether standard (...) criteria include measurements of all brain functions, and how minorities who reject whole-brain-based definitions should be accommodated. These controversies leave little hope of consensus on how to define death for social and public policy purposes. Rather, there is persistent disagreement among proponents of three major groups of definitions of death: whole-brain, cardiocirculatory or somatic, and higher-brain. Given the persistence and reasonableness of each of these groups of definitions, public policy should permit individuals and their valid surrogates to choose among them. (shrink)

After distinguishing two different meanings of the notion of a morality internal to medicine and considering a hypothetical case of a society that relied on its surgeons to eunuchize priest/cantors to permit them to play an important religious/cultural role, this paper examines three reasons why morality cannot be derived from reflection on the ends of the practice of medicine: (1) there exist many medical roles and these have different ends or purposes, (2) even within any given medical role, there exists (...) multiple, sometimes conflicting ends, and, most critically, (3) the ends of any practice such as medicine must come from outside the practice, that is, from the basic ends or purposes of human living. The paper concludes by considering whether these ends external to medicine are universally part of the moral reality or whether they are socially constructed. The paper argues that, even if various cultural accounts of the common, universal morality are socially constructed, they may, nevertheless, be reflections, however, imperfect, of a more universal common morality that should be thought of as real. Therefore, the morality of medicine must come from a more fundamental morality external to medicine. That external morality will be socially constructed, but may nevertheless reflect an underlying common morality. (shrink)

In its October 2001 issue, this journal published a series of articles questioning the Whole-Brain-based definition of death. Much of the concern focused on whether somatic integration - a commonly understood basis for the whole-brain death view - can survive the brain's death. The present article accepts that there are insurmountable problems with whole-brain death views, but challenges the assumption that loss of somatic integration is the proper basis for pronouncing death. It examines three major themes. First, it accepts the (...) claim of the "disaggregators" that some behaviors traditionally associated with death can be unbundled, but argues that other behaviors (including organ procurement) must continue to be associated. Second, it rejects the claims of the "somaticists," that the integration of the body is critical, arguing instead for equating death with the irreversible loss of "embodied consciousness," that is, the loss of integration of bodily and mental function. Third, it defends higher-brain views against the charge that they are necessarily "mentalist," that is, that they equate death with losing some mental function such as consciousness or personhood. It argues, instead, for the integration of bodily and mental function as the critical feature of human life and that its irreversible loss constitutes death. (shrink)

The dead donor rule (DDR) governs procuring life-prolonging organs. They should be taken only from deceased donors. Miller and Truog have proposed abandoning the rule when patients have decided to forgo life-sustaining treatment and have consented to procurement. Organs could then be procured from living patients, thus killing them by organ procurement. This proposal warrants careful examination. They convincingly argue that current brain or circulatory death pronouncement misidentifies the biologically dead. After arguing convincingly that physicians already cause death by withdrawing (...) treatment, they claim no bright-line differences preclude organ removal from the living. The argument fails for those who accept the double effect doctrine or other grounds for distinguishing forgoing life support from active, intentional killing. If the goal is determining irreversible loss of somatic function, they correctly label current death pronouncement a “legal fiction.” Recognizing a second, public policy meaning of the term death provides grounds for maintaining the DDR without jeopardizing procurement. (shrink)

While twentieth-century medical ethics has focused on the duty of physicians to benefit their patients, the next century will see that duty challenged in three ways. First, we will increasingly recognize that it is unrealistic to expect physicians to be able to determine what will benefit their patients. Either they limit their attention to medical well-being when total well-being is the proper end of the patient or they strive for total well-being, which takes them beyond their expertise. Even within the (...) medical sphere, they have no basis for choosing among the proper medical goals for medicine. Also, there are many plausible strategies for relating predicted benefits to harms, and physicians cannot be expert in picking among these strategies. Second, increasingly plausible ethical systems recognize that in some cases, patient benefit must be sacrificed to protect patient rights including the right to the truth, to have promises kept, to have autonomy respected, and to not be killed. Third, ethics of the next century will increasingly recognize that some patient benefits must be sacrificed to fulfill duties to others - either the duty to serve the interests of others or other duties such as keeping promises, telling the truth, and, particularly, promoting justice. Physicians in the twenty-first century will be seen as having a new, more limited duty to assist the patient in pursuing the patient's understanding of the patient's interest within the constraints of deontological ethical principles and externally imposed duties to promote justice. The result will be a duty to be loyal to the consumer of health care with the recognition that often this will mean that the physician is not permitted to pursue the physician's understanding of the patient's well-being. (shrink)

The origins of professional ethical codes and oaths are explored. Their legitimacy and usefulness within the profession are questioned and an alternative ethical source is suggested. This source relies on a commonly shared, naturally knowable set of principles known as common morality.

We are living in an unprecedented era of biomedical revolution. Medicine is remaking humans, and controversy surrounds such topics as abortion, artificial organs, brain circuitry, eugenics, euthanasia, and gene therapy. At the same time, medical advances are posing complex ethical problems for both patients and professionals. The most comprehensive and up-to-date collection of its kind, Case Studies in Biomedical Ethics: Decision-Making, Principles, and Cases explores fundamental ethical questions arising from real situations faced by health professionals, patients, and others. Featuring a (...) wide range of more than 100 case studies drawn from current events, court cases, and physicians' experiences, the book is divided into three parts. Part I presents a basic framework for ethical decision-making in healthcare, covering such issues as separating evaluative questions from questions of fact; distinguishing between ethical and nonethical evaluations; and identifying the source of ethical judgments. Expanding upon this framework, Part II explains the ethical principles: beneficence and nonmaleficence, justice, respect for autonomy, veracity, fidelity, and avoidance of killing. Parts I and II provide students with the background to analyze the ethical dilemmas presented in Part III, which features cases on a broad spectrum of issues including abortion, genetics, mental health, confidentiality, health insurance, experimentation on humans, the right to refuse treatment, and death and dying. Each case is accompanied by the authors' commentary, which guides students in considering the issues. Ideal for undergraduate and graduate courses in biomedical ethics, bioethics, and medical ethics, Case Studies in Biomedical Ethics incorporates opening text boxes in each chapter that cross-reference relevant cases in other chapters. It also includes an appendix of important ethical codes and a glossary of key terms. (shrink)

The current definition of death used for donation after cardiac death relies on a determination of the irreversible cessation of the cardiac function. Although this criterion can be compatible with transplantation of most organs, it is not compatible with heart transplantation since heart transplants by definition involve the resuscitation of the supposedly "irreversibly" stopped heart. Subsequently, the definition of "irreversible" has been altered so as to permit heart transplantation in some circumstances, but this is unsatisfactory. There are three available strategies (...) for solving this "irreversibility problem": altering the definition of death so as to rely on circulatory irreversibility, rather than cardiac; defining death strictly on the basis of brain death (either whole-brain or more pragmatically some higher brain criteria); or redefining death in traditional terms and simultaneously legalizing some limited instances of medical killing to procure viable hearts. The first two strategies are the most ethically justifiable and practical. (shrink)

The puzzling case of the broken arm -- Hernias, diets, and drugs -- Why physicians cannot know what will benefit patients -- Sacrificing patient benefit to protect patient rights -- Societal interests and duties to others -- The new, limited, twenty-first-century role for physicians as patient assistants -- Abandoning modern medical concepts: doctor's "orders" and hospital "discharge" -- Medicine can't "indicate": so why do we talk that way? --"Treatments of choice" and "medical necessity": who is fooling whom? -- Abandoning informed (...) consent -- Why physicians get it wrong and the alternatives to consent: patient choice and deep value pairing -- The end of prescribing: why prescription writing is irrational -- The alternatives to prescribing -- Are fat people overweight? -- Beyond prettiness: death, disease, and being fat -- Universal but varied health insurance: only separate is equal -- Health insurance: the case for multiple lists -- Why hospice care should not be a part of ideal health care I: the history of the hospice -- Why hospice care should not be a part of ideal health care II: hospice in a postmodern era -- Randomized human experimentation: the modern dilemma -- Randomized human experimentation: a proposal for the new medicine -- Clinical practice guidelines and why they are wrong -- Outcomes research and how values sneak into finding of fact -- The consensus of medical experts and why it is wrong so often. (shrink)

: Research by Siminoff and colleagues reveals that many lay people in Ohio classify legally living persons in irreversible coma or persistent vegetative state (PVS) as dead and that additional respondents, although classifying such patients as living, would be willing to procure organs from them. This paper analyzes possible implications of these findings for public policy. A majority would procure organs from those in irreversible coma or in PVS. Two strategies for legitimizing such procurement are suggested. One strategy would be (...) to make exceptions to the dead donor rule permitting procurement from those in PVS or at least those who are in irreversible coma while continuing to classify them as living. Another strategy would be to further amend the definition of death to classify one or both groups as deceased, thus permitting procurement without violation of the dead donor rule. Permitting exceptions to the dead donor rule would require substantial changes in law—such as authorizing procuring surgeons to end the lives of patients by means of organ procurement—and would weaken societal prohibitions on killing. The paper suggests that it would be easier and less controversial to further amend the definition of death to classify those in irreversible coma and PVS as dead. Incorporation of a conscience clause to permit those whose religious or philosophical convictions support whole-brain or cardiac-based death pronouncement would avoid violating their beliefs while causing no more than minimal social problems. The paper questions whether those who would support an exception to the dead donor rule in these cases and those would support a further amendment to the definition of death could reach agreement to adopt a public policy permitting organ procurement of those in irreversible coma or PVS when proper consent is obtained. (shrink)

INTRODUCTION Five Questions of Ethics Medical ethics as a field presents a fundamental problem. As a branch of applied ethics, medical ethics becomes ...

Medical ethics changed dramatically in the past 30 years because physicians and humanists actively engaged each other in discussions that sometimes led to confrontation and controversy, but usually have improved the quality of medical decision-making. Before then medical ethics had been isolated for almost two centuries from the larger philosophical, social, and religious controversies of the time. There was, however, an earlier period where leaders in medicine and in the humanities worked closely together and both fields were richer for it. (...) This volume begins with the 18th century Scottish Enlightenment when professors of medicine such as John Gregory, Edward Percival, and the American, Benjamin Rush, were close friends of philosophers like David Hume, Adam Smith, and Thomas Reid. They continually exchanged views on matters of ethics with each other in print, at meetings of elite intellectual groups, and at the dinner table. Then something happened, physicians and humanists quit talking with each other. In searching for the causes of the collapse, this book identifies shifts in the social class of physicians, developments in medical science, and changes in the patterns of medical education. Only in the past three decades has the dialogue resumed as physicians turned to humanists for help just when humanists wanted their work to be relevant to real-life social problems. Again, the book asks why, finding answers in the shift from acute to chronic disease as the dominant pattern of illness, the social rights revolution of the 1960's, and the increasing dissonance between physician ethics and ethics outside medicine. The book tells the critical story of how the breakdown in communication between physicians and humanists occurred and how it was repaired when new developments in medicine together with a social revolution forced the leaders of these two fields to resume their dialogue. (shrink)

The physician who upholds the Hippocratic oath is supposed to be loyal to his or her patients. This requires choosing only the therapy that the physician believes is best for the patient. However, knowing what is best requires randomized clinical trials. Thus, clinicians must be willing to recruit their patients to be assigned at random to one of two therapies in order to determine which is best based on the highest standards of pharmacological science.

The concept of care and a related ethical theory of care have emerged as increasingly important in biomedical ethics. This essay outlines a series of questions about the conceptualization of care and its place in ethical theory. First, it considers the possibility that care should be conceptualized as an alternative principle of right action; then as a virtue, a cluster of virtues, or as a synonym for virtue theory. The implications for various interpretations of the debate of the relation of (...) care and justice are then explored, suggesting three possible meanings for that contrast. Next, the possibility that care theorists are taking up the debate over the relation between principles and cases is considered. Finally, it is suggested that care theorists may be pressing for consideration of an entirely new question in moral theory: the assessment of the normative appropriateness of relationships. Issues needing to be addressed in an ethic of relationships are suggested. (shrink)

It is commonly believed in research ethics that some form of equipoise is a necessary condition for justifying randomized clinical trials, that without it clinicians are violating the moral duty to do what is best for the patient. Recent criticisms have shown how complex the concept of equipoise is, but often retain the commitment to some form of equipoise for randomization to be justified. This article rejects that claim. It first asks for what one should be equally poised (scientific or (...) clinical equipoise), then asks who should be equally poised (scientist, clinician, or subject), and finally asks why any of these players need be equally poised between treatment options. The article argues that only the subject's evaluation of the options is morally relevant and that even the subject need not be equally poised or indifferent between the options in order to volunteer for randomization. All that is needed is adequately informed, free, and unexploited consent. It concludes equipoise is irrelevant. (shrink)

While much attention has been given to the use of principles in biomedical ethics and increasing attention is given to alternative theoretical approaches, relatively little attention has been devoted to the critical task of how one resolves conflicts among competing principles. After summarizing the system of principles and some problems in conceptualizing the principles, several strategies for reconciling conflicts among principles are examined including the use of single-principle theories (pure libertarianism, pure utilitarianism, and pure Hippocratism), balancing theories, conflicting appeals theories, (...) and lexical ordering. Then a mixed strategy is proposed in which consequentialist principles are balanced between themselves as are nonconsequentialist principles, after which the result of balancing the nonconsequentialist principles is lexically ranked over the result of balancing the consequentialist ones. Finally, strategies involving specifying and rule generation are discussed concluding that most current specification and rule-generating theories must involve some degree of lexical ordering of principles. (shrink)

: Free-market libertarians have long supported incentives to increase organ procurement, but those oriented to justice traditionally have opposed them. This paper presents the reasons why those worried about justice should reconsider financial incentives and tolerate them as a lesser moral evil. After considering concerns about discrimination and coercion and setting them aside, it is suggested that the real moral concern should be manipulation of the neediest. The one offering the incentive (the government) has the resources to eliminate the basic (...) needs that pressure the poor into a willingness to sell. It is unethically manipulative to withhold those resources and then offer payment for organs. Nevertheless, the poor have been left without basic necessities for 20 years since the passage of the prohibition on incentives. As long as the government continues to withhold a decent minimum of welfare, liberals should, with shame, cease opposing financial incentives for organ procurement. (shrink)

Twelve contributors discuss critical issues affecting medical ethics. Topics include: the normative principles of medical ethics, concepts of health and disease, the physician-patient relationship, human experimentation, informed consent, genetics, ethical issues in organ transplantation, and moral.

When The Ad Hoc Committee of Harvard Medical School to Examine the Definition of Brain Death began meeting in 1967, I was a graduate student, with committee member Ralph Potter and committee chair Henry Beecher as my mentors. The question of when to stop life support on a severely compromised patient was not clearly differentiated from the question of when someone was dead. A serious clinical problem arose when physicians realized that a patient's condition was hopeless but life support perpetuated (...) body function. Thus, the committee stated that its first purpose was to deal with the burdens on patients and families as well as on hospitals and on patients needing hospital beds occupied by comatose patients. They intuited the strategy of “defining” these patients as dead, thus legitimating treatment stoppage. They noted that this would also serve a second purpose. Although the dead donor rule had not yet been clearly articulated, they claimed that defining patients as dead would also address controversy over obtaining organs for transplant.My mentors’ discussions related to my interest in the intersection between questions primarily of medical fact (When has a human brain irreversibly ceased functioning?) and nonmedical questions of social policy (Should we treat individuals with dead brains and beating hearts as dead humans?). It quickly became clear that most committee members did not appreciate the interplay of these questions. (shrink)

Our society is increasingly confronting the questions of whether health care can and should be limited on economic considerations. While it is tempting to use utilitarian‐based, cost‐benefit analysis in such decisions, only principles of procedural and substantive justice can provide solid moral grounds for using economic criteria to set limits on care. An ethic of justice can inform the development of guidelines for health planners in policies to limit care for the terminally ill and the nonterminal elderly.

Recognition of the need to ration care has focused attention on the concept of "basic care." It is often thought that care that is "basic" is also morally prior. This article questions that premise in light of the usual definitions of "basic." Specifically, it argues that Oregon's rationing scheme, which defines "basic" in terms of cost-effective care, fails to pay sufficient attention to important ethical principles such as justice.

In lieu of an abstract, here is a brief excerpt of the content:Kennedy Institute of Ethics Journal 13.3 (2003) 189-192 [Access article in PDF] Is There a Common Morality? Robert M. VeatchSenior EditorOne of the most exciting and important developments in recent ethical theory—especially bioethical theory—is the emergence of the concept of "common morality." Some of the most influential theories in bioethics have endorsed the notion using it as the starting point of their systems. This issue of the Journal (...) is devoted to these developments.The core idea of a common morality is that all humans—at least all morally serious humans—have a pretheoretical awareness of certain moral norms. The claim is that normal humans intuit or in some other way know that there is something wrong with things like lying or breaking promises or killing people. These purportedly universally shared insights can provide the raw data from which ethical theories are constructed. As such, they are perhaps analogous to the raw sense data that are relied on in the natural sciences to launch the construction of scientific theories and accounts of the nature of reality. Some common morality theorists suggest an analogy between the natural and the moral sciences.In the natural sciences there is a widely shared belief that some raw sensory data are perceived by all normal humans and provide the basis for the construction of various scientific theories. For example, it is widely believed that all normal humans looking at the top light on a traffic signal perceive something that in English is called "red." Of course, different cultures will use different language to describe this experience. They may parse the boundaries differently (varying on the exact borderline between red and orange), provide widely differing accounts of why the experience of "red" occurs, and eventually generate significantly different theoretical formulations to explain the experience of redness. Moreover, some individuals may look at that top light of the traffic signal and not see color at all. One generally, however, does not account for this by denying there is any objective, generally shared basis for the experience that produces a sensation of redness in normal people. One simply explains the experience of the one who fails to see color by positing a defect in perception, called "color-blindness."Some moral theorists suggest that something analogous happens when humans look at the moral scene. The claim is that all normal humans in all places and cultures "see" certain moral requiredness. They see that some behaviors are, in some sense, generally wrong; that other behaviors are generally right; that [End Page 189] some character traits are generally praiseworthy, others blameworthy. No sophisticated common morality theorist denies that, as with color-blindness, there may be occasional outliers who for one reason or another fail to intuit or perceive these simple, abstract moral norms. Certainly, people in different cultures will define the terms differently, will recognize different limits on the norms, and will construct different theories to account for their experience. The primitive idea that there is something generally wrong with killing other humans will be articulated very differently in different cultures—some referring to the "sacredness of life;" others to a duty not to kill, a right to life, or a prohibition on killing the innocent. Some may extend the insight to a duty to prolong living, others limit it merely to a prohibition of direct, active killing. Some may endorse more exceptions—for killing of unjust aggressors, for killing in just war, for killing in self-defense; others, such as pacifists, will be much more stingy in doling out exceptions. Certainly, people at different times and places will articulate the norms in different language and embed them in different theories. The basic claim of common morality theorists, however, is that there is some primitive, pretheoretical insight that is shared by all normal, morally serious persons.Recently, the notion of a common morality has served as a starting point for bioethical theories as diverse as Bernard Gert, Charles Culver, and Danner Clouser's Bioethics: A Return to Fundamentals (1997) and the latest edition of Tom Beauchamp and James Childress's Principles of Biomedical Ethics... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:IntroductionRobert M. Veatch (bio)The Kennedy Institute of Ethics regularly sponsors intensive bioethics courses for physicians, nurses, and other health care professionals. While the basic course, held in June of each year, provides a general introduction to bioethics, advanced courses, which are often held in March, focus on more specific topics such as death and dying, justice and the allocation of resources, or theories and methods in bioethics. This (...) year the advanced course addressed one of the most sensitive and complex bioethical issues of our day: managed care. This issue of the Kennedy Institute of Ethics Journal includes revised versions of many of the papers from that meeting.As defined by one of the papers in this issue, managed care involves a system of health care delivery that manages resources, quality, and access associated with the delivery of health care. The key element of managed care is that, for the first time, managers—often from outside the health care professions—are intentionally controlling resources, and therefore controlling health care professional decisions that use those resources. The objective is not merely to eliminate utterly useless interventions—no one could plausibly object to that. Rather the target is also the elimination of inefficient and wasteful resource consumption. Increasingly, we recognize that many diagnostic tests and treatments offer, at best, a very marginal chance of doing the patient good. Some of these come at considerable cost. From the point of view of the rational organization of resources, no rational person would insist on receiving every last procedure that offers only a tiny chance to do a small amount of good at great cost. Managed care is designed to bring to consciousness and rationalize the decisions about which of these marginal, expensive benefits are worth pursuing.The problem is that any effort to eliminate any of the these expensive marginal services flies directly in the face of the Hippocratic ethic. Physicians and other clinicians traditionally are trained to believe that it is their moral duty to do what is best for the patient. Only now are we realizing that, taken literally, no rational person would want literally the best possible care, assuming that such care would include thousands of long-shot, expensive efforts to get the most modest of benefits at great cost. In a world of finite resources, rational people would certainly want very good medical care; they would want reasonable care. But they would also want some criteria of efficiency and fairness applied. The Hippocratic tradition has never addressed the problem of the difference between the best care and care that is of very high quality, but is chosen with an awareness that the best in medicine will necessarily come at the price of potentially serious [End Page vii] deprivation in other spheres of life. The ethics of managed care is fundamentally an exploration of how health care professionals can reconcile their traditional, if short-sighted and naive, commitment to doing what is best for their patients with increasing realism about the absurdity of pursuing every last possible increment of benefit.To the clinical health care professional, the issue raised most poignantly by managed care is whether the various health professions can still be practiced with integrity in a setting in which outsiders are charged with the rationalization and systematization of limits placed on excessive use of marginally beneficial resources. Edmund D. Pellegrino, a clinician and former Director of the Kennedy Institute, sets the tone for the course and for this issue of the Journal by making an appeal for the retention of the highest ethical standards of integrity for clinicians practicing in a managed care setting. He is unwilling to let standards be lowered in the process of systematizing the rational use of health care resources. The remaining papers in this issue respond to those pressures to change the nature of the clinical lay-professional relationship. Some of these presentations originated as panels designed to bring out varying points of view. The published form of the presentations, like the original oral remarks, are of different lengths. All have been edited by the presenters, some taking on the form of more finished papers, others still reflecting the less formal conversation of... (shrink)

The single most important intellectual event in my career in medical ethics occurred the day I realized that the Hippocratic ethic for medicine was not merely outdated and irrelevant but actually in conflict with all the dominant religious and secular moral traditions of our day. Whether one stood in any of the great modern religious traditions or in any of the camps of secular philosophy—the liberal tradition of political philosophy, Marxism, or more recent feminist or communitarian views—the Hippocratic ethic was (...) wrong, both metaethically and normatively. (shrink)

The Foundations of Justice: Why the Retarded and the Rest of Us Have Claims to Equality. By Robert M. Veatch.