The article offers an approach to inquiry about, the foundation of medical ethics by addressing three areas of conceptual presupposition basic to medical ethical theory. First, medical ethics must presuppose a view about the nature of medicine. it is argued that the view required by a cogent medical morality entails that medicine be seen both as a healing relationship and as a practical art. Three ways in which medicine inherently involves values and valuation are presented as important, i.e., in being (...) aimed at the good of health, in being a cognitive art evaluating towards that good, and as a manifestation of a virtuous disposition concerning that good. Finally, a value ontology drawn from these considerations is seen as necessarily underlying medical ethics. A set of three such basic values are promoted as crucial: the value of health; the value of the individual patient; and the value of altruism that mediates the class of potential patients. (shrink)

Our global knowledge of different cultures and the diversity of values increases almost daily. New challenges arise for ethics. This is especially true in the field of bioethics because the technological progress of medicine throughout the world is causing dramatic interactions with traditionally held values. Science and technology are rapidly advancing beyond discussions and corresponding political struggles over human rights, leaving those debates behind. This rapid development of science is at odds with the principle of sustained development that calls for (...) measured and thoughtful planning, such that no new idea should rupture the delicate fabric of communities, environment, and cultural evolution. (shrink)

Increasingly, the world seems to shrink due to our ever-expanding technological and communication capacities. Correspondingly, our awareness of other cultures increases. This is especially true in the field of bioethics because the technological progress of medicine throughout the world is causing dramatic and challenging intersections with traditionally held values. Think of the use of pregnancy monitoring technologies like ultrasound to abort fetuses of the “wrong” sex in India, the sale of human organs in and between countries, or the disjunction between (...) the haves and the have-nots in South America when it comes to bone marrow transplants, while thousands of other children die for want of fundamental goods and services like clean water, basic inoculations, and food itself. (shrink)

Considerable debate has occurred about the proper role of philosophers when offering ethics consultations. Some argue that only physicians or clinical experienced personnel should offer ethics consultations in the clinical setting. Others argue still further that philosophers are ill-equipped to offer such advice, since to do so rests on no social warrant, and violates the abstract and neutral nature of the discipline itself.I argue that philosophers not only can offer such consultations but ought to. To be a bystander when one's (...) discipline does offer insights and methods of value discernment is pusillanimous. But this position requires a view of clinical medical ethics as one that arises out of the clinical practice of medicine, and not just from an application of general ethical principles to the practice of medicine. I conclude with some skills that trained philosophers can bring to the consultation service, and note that all consultations are in the form of recommendations that the patient, family, and physician are still free to accept or reject. Philosophers in the clinical setting do not make decisions. (shrink)

Increasingly, the world seems to shrink due to our ever-expanding technological and communication capacities. Correspondingly, our awareness of other cultures increases. This is especially true in the field of bioethics because the technological progress of medicine throughout the world is causing dramatic and challenging intersections with traditionally held values. Think of the use of pregnancy monitoring technologies like ultrasound to abort fetuses of the “wrong” sex in India, the sale of human organs in and between countries, or the disjunction between (...) the haves and the have-nots in South America when it comes to bone marrow transplants, while thousands of other children die for want of fundamental goods and services like clean water, basic inoculations, and food itself. (shrink)

According to Frankena, “the moral point of view is what Alison Wilde and Heather Badcock did not have.” Most of us, however, are not such extreme examples. We are capable of the moral point of view, but we fail to take the necessary time or make the required efforts. We resist pulling ourselves from other distractions to focus on the plight of others and what we might do to ameliorate their suffering. Perhaps compassion is rooted in understanding what it is (...) that connects us with others rather than what separates us, and rests on developing sufficient awareness, to internalize what our actions, or lack of them, mean in the lives of others. (shrink)

Against the backdrop of ancient, mediaeval and modern Catholic teaching prohibiting killing (the rule against killing), the question of assisted suicide and euthanasia is examined. In the past the Church has modified its initial repugnance for killing by developing specific guidelines for permitting killing under strict conditions. This took place with respect to capital punishment and a just war, for example. One wonders why in the least objectionable instance, when a person is already dying, suffering, and repeatedly requesting assistance in (...) dying, there is still such widespread condemnation of assisted suicide and euthanasia. In a Gedankexperiment, I suggest that certain stories of martyrdom in the history of the Christian Church shed some light on the role of taking one’s life, or putting one’s life in danger out of love. I further suggest that requesting assisted suicide and/or euthanasia from the motive of love of one’s family or care givers might possibly qualify as one instance of justifiable euthanasia, although I acknowledge that the Church will not be making changes in its stance any time soon. (shrink)

There are several branches of ethics. Clinical ethics, the one closest to medical decisionmaking, can be seen as a branch of medicine itself. In this view, clinical ethics is a unitary hermeneutics. Its rule is a guideline for unifying other theories of ethics in conjunction with the clinical context. Put another way, clinical ethics interprets the clinical situation in light of a balance of other values that, while guiding the decisionmaking process, also contributes to the very weighting of those values. (...) The case itself originates ideas, not only about which value ought to predominate in its resolution, but also provides the origin of clinical rules that can be used in other cases. These are interpretive rules. Some examples of these rules are presented as well. (shrink)

The combination of genuine ethical concerns and fear of learning to use germ-line therapy for human disease must now be confronted. Until now, no established techniques were available to perform this treatment on a human. Through an integration of several fields of science and medicine, we have developed a nine step protocol at the germ-line level for the curative treatment of a genetic disease. Our purpose in this paper is to provide the first method to apply germ-line therapy to treat (...) those not yet born, who are destined to have a life threatening, or a severely debilitating genetic disease. We hope this proposal will initiate the process of a thorough analysis from both the scientific and ethical communities. As such, this proposal can be useful for official groups studying the advantages and disadvantages of germ-line therapy. (shrink)

Past ages of medical care are condemned in modern philosophical and medical literature as being too paternalistic. The normal account of good medicine in the past was, indeed, paternalistic in an offensive way to modern persons. Imagine a Jean Paul Sartre going to the doctor and being treated without his consent or even his knowledge of what will transpire during treatment! From Hippocratic times until shortly after World War II, medicine operated in a closed, clubby manner. The knowledge learned in (...) medicine was not shared with the patients, who were in general poorly educated and for the most part completely ignorant of the craft of medicine and the physicians. Physicians were cautioned against telling patients too much about their Illness and/or their recovery, perhaps because physicians themselves did not have an enormous armamentarium to confront disease. (shrink)

Past ages of medical care are condemned in modern philosophical and medical literature as being too paternalistic. The normal account of good medicine in the past was, indeed, paternalistic in an offensive way to modern persons. Imagine a Jean Paul Sartre going to the doctor and being treated without his consent or even his knowledge of what will transpire during treatment! From Hippocratic times until shortly after World War II, medicine operated in a closed, clubby manner. The knowledge learned in (...) medicine was not shared with the patients, who were in general poorly educated and for the most part completely ignorant of the craft of medicine and the physicians (but not, perhaps, of folk medicine). Physicians were cautioned against telling patients too much about their Illness and/or their recovery, perhaps because physicians themselves did not have an enormous armamentarium to confront disease. (shrink)

In June 1993, conjoined twins Amy and Angela Lakeberg became the focus of national attention. They shared a complex six‐chambered heart and one liver; only one could survive separation surgery, and even her chances were slim. The medical challenge was great and the ethical challenges were even greater.

In advanced technological societies there is growing concern about the prospect of protracted deaths marked by incapacitation, intolerable pain and indignity, and invasion by machines and tubing. Life prolongation for critically ill cancer patients in the United States, for example, literally costs a fortune for very little benefit, typically from $82,845 to $189,339 for an additional year of life. Those who return home after major interventions live on average only 3 more months; the others live out their days in a (...) hospital intensive care unit. (shrink)

Medical ethics is a footnote to the larger problem of directing our technology to good human ends. Written large, then, medical ethics must ask five basic questions.

Populations around the world are aging at a very fast rate, so much so that care for the elderly will soon rupture even the most carefully planned, enlightened care provisions societies can offer. The demographics in advanced countries demonstrate this dilemma, even without projections based on antiaging medications that may be possible in the near future, and a healthier lifestyle that has preoccupied the yuppies for about 10 years.

The problem of developing a moral philosophy of medicine is explored in this essay. Among the challenges posed to this development are the general mistrust of moral philosophy and philosophy in general created by post-modernist philosophical and even anti-philosophical thinking. This reaction to philosophical systematization is usually called antifoundationalism. I distinguish different forms of antifoundationalism, showing that not all forms of their opposites, foundationalism, are alike, especially with regards to claims made about the certitude of moral thought. I conclude that (...) we are correct to mistrust absolutist principles in a moral philosophy of medicine, but can find some center within the practice of medicine itself for a moral foundation. (shrink)

In this essay I will examine why the truth is so important to human communication in general, the types of truth, and why truth is only a relative value. After those introductory points, I will sketch the ways in which the truth is overridden or trumped by other concerns in the clinical setting. I will then discuss cases that fall into five distinct categories. The conclusion emphasizes the importance of truth telling and its primacy among secondary goods in the healthcare (...) professional-patient relationship. (shrink)

According to Frankena, “the moral point of view is what Alison Wilde and Heather Badcock did not have.” Most of us, however, are not such extreme examples. We are capable of the moral point of view, but we fail to take the necessary time or make the required efforts. We resist pulling ourselves from other distractions to focus on the plight of others and what we might do to ameliorate their suffering. Perhaps compassion is rooted in understanding what it is (...) that connects us with others rather than what separates us, and rests on developing sufficient awareness, to internalize what our actions, or lack of them, mean in the lives of others. (shrink)

Physicians have long aided their patients in dying in an effort to ease human suffering. It is only in the nineteenth and twentieth centuries that the prolongation of life has taken on new meaning due to the powers now available to physicians, through new drugs and high technology interventions. Whereas earlier physicians and patients could readily acknowledge that nothing further could be done, today that judgment is problematic.Most often, aiding the dying took the form of not doing anything further to (...) prolong life. Morally, this act of restraint was not difficult, because few options could have been considered. However, some physicians, rarely, would help patients die either by hastening death directly or by increasing pain control with the risk of hastening death, the so-called double effect. When directly hastening death, physicians either directly caused the death of the patient through euthansia, or supplied the means to the patient to bring about death with or without encouragement to use these means. The latter is physician-assisted suicide. (shrink)

Persons of diminished capacity, especially those who are still legally competent but are de facto incompetent should still be able to participate in moderately risky research projects that benefit the class of persons with similar diseases. It is argued that this view can be supported with a modified communitarianism, a philosophy ofmedicine that holds that health care is a joint responsibility that meets foundational human needs. The mechanism for obtaining a substituted consent I call ``community consent,'' and distinguish this from (...) the usual family or surrogate consent for treatment. Care givers are included in the community that might consent for an individual who has no identifiable family members. (shrink)

In Márquez's OfLoveandOtherDemons Abrenuncio the physician and the Marquis discuss the outbreak of rabies that is the centerpiece of the book, since the Marquis' daughter has been bitten by a rabid dog. Abrenuncio notes that the poor.

Let us look at autonomy in a new way. Autonomy has a richly deserved place of honor in bioethlcs. It has led the set of principles that formed the basis of the discipline since the beginning. It is the leading principle In what is now regularly called “the Georgetown Mantra,” a phrase suggested by one of the first philosophers ever to be hired In a medical school, K. Danner Clouser. The phrase applies to the principled approach of autonomy, beneficence, nonmaleficence, (...) and justice. This kind of bioethics was developed by scholars like Beauchamp and Childress, Veatch, and Engelhardt, during their association with Georgetown University. (shrink)

Pellegrino's philosophy of medicine is explored in categories such as the motivation in constructing a philosophy of medicine, the method, the starting point of the doctor-patient relationship, negotiation about values in this relationship, the goal of the relationship, the moral basis of medicine, and additional concerns in the relationship (concerns such as gatekeeping, philosophical anthropology, axiology, philosophy of the body, and the general disjunction between science and morals). A critique of this philosophy is presented in the following areas: methodology, relation (...) to ontology and sociology, the dynamic of individual and social concerns, and the new social condition of medicine. Finally, some suggestions for the future revitalization of philosophy of medicine are made based on Pellegrino's ideas. The focus throughout is on the moral basis and moral consequences of the philosophy of medicine, and not on other important themes. Keywords: doctor-patient relationship, goal of medicine, medical ethics, philosophical method, philosophy of medicine, philosophy of the body, values in medicine CiteULike Connotea Del.icio.us What's this? (shrink)

Physicians have long aided their patients in dying in an effort to ease human suffering. It is only in the nineteenth and twentieth centuries that the prolongation of life has taken on new meaning due to the powers now available to physicians, through new drugs and high technology interventions. Whereas earlier physicians and patients could readily acknowledge that nothing further could be done, today that judgment is problematic.Most often, aiding the dying took the form of not doing anything further to (...) prolong life. Morally, this act of restraint was not difficult, because few options could have been considered. However, some physicians, rarely, would help patients die either by hastening death directly or by increasing pain control with the risk of hastening death, the so-called double effect. When directly hastening death, physicians either directly caused the death of the patient through euthansia, or supplied the means to the patient to bring about death with or without encouragement to use these means. The latter is physician-assisted suicide. (shrink)

During 1992, academic bioethicists celebrated the 30th anniversary of bioethics. Some like to date the origin of modern secular bioethics to the advent of transplant technology that began with kidney transplantation in the early 1960s in the Seattle, Washington, area. This is certainly a good candidate for a starting point. Another might be the work of Joseph Fletcher in the New York area with the Euthanasia Society of America and with clergy training. Still another candidate for the origins of secular (...) bioethics would be the trial of physicians at the University of Virginia for transplanting a kidney at which the same Joseph Fletcher testified. At that trial, the alteration occurred in American law from a definition of death that focused on the cessation of heartbeat to one that focused on the cessation of brain function. (shrink)

You wrote an editorial in JAMA giving a 30-year retrospective on bioethics. If you look ahead to the next 30 years, what are the issues you see facing bioethics in the future?

The first book on my shelf at the newly created Program on Human Values and Health Sciences at the University of Tennessee Center for the Health Sciences in Memphis was by Van Rensselaer Potter on Global Bioethics. He was a cancer specialist at the University of Wisconsin and had the vision that bioethics should be a global concern—global in terms of scope, disciplines involved, and relationship to the environment and cultural context. This view has shaped my own career as well (...) as influencing many others. (shrink)

From time to time medical ethicists bemoan the loss of a religious perspective in medical ethics. The discipline had its origins in the thinking of explicitly religious thinkers such as Paul Ramsey and Joseph Fletcher. Furthermore, many of those who contributed to the early development of the discipline had training in theology. One thinks of Daniel Callahan, Richard McCormick, Albert Jonsen, Sam. Banks. As the discipline becomes more and more self-reflective, with attention being paid to methodological and conditional concerns, it (...) is only natural that the roots are due for a reexamination. The time has therefore come for some reassessment. The first steps here are taken in the form of a dialogue between the coauthors to clarify authentic contributions and weed out unauthentic ones. (shrink)

At the end of this century there are so many occasions, so many residues of the most violent of times, that challenge the very idea of forgivenessNorthern Ireland, Bosnia, the Tutsis and Hutus, the Shiite and Suni Moslems, the settlers and African immigrants in South Africa, indigenous populations against the dominant culture. The open violence and rapaciousness of human enmity can be viewed now in the displacement of masses of people in Kosovo. Said the U.N. High Commissioner for Refugees, Sadako (...) Ogata, about the Kosovo crisis: that this century, as in its darkest hours, should end with the mass deportation of innocent people.”. (shrink)

Can it be already 30 years since the first days of modern, secular bioethics? As those of us in the field for almost all these years arrive near the end of our careers, we find that time has truly flown and the challenges have not diminished one bit. If anything, they are even greater than in the early years. Along the way it was tempting to think that the broad consensus reached on research ethics, on the four principles, on the (...) need for consent in clinical ethics, and then on rights in reproduction and dying, would paint the picture rather well. Only fill-in would be needed by the apprentices coming afterward. Yet time and again new biological and medical discoveries continued to challenge that painting. A new canvas had to be hung. Among the major newer developments were the challenges of healthcare reform, genetics, antifoundationalism, the certification of ethics consultants, and now, the internationalization of bioethics, its relationship to the environment and world politics, and biotechnology. (shrink)

The behavior of people in the presence of scarce resources has long been a source of ethical concern and debate. Many of the responses, ranging from outright brutality and cheating on the one hand to altruism, nobility, and sacrifice on the other, were most recently demonstrated in the movie Titanic. It should come as no surprise, then, that rational efforts to allocate the very scarce life-saving resource of organs are sometimes circumvented by these natural human impulses and sheer human creativity. (...) This is especially true when the organs in question are required for continued life and cannot be temporarily or permanently replaced by technology. Thus the focus of this paper will be on the competition for livers. (shrink)

Thomasma and Graber, medical ethics theorists and clinical practitioners, present a definitive examination of the actions that fall under the aegis of euthanasia--the art of painlessly putting to death persons suffering from incurable conditions or diseases. They distinguish active euthanasia as an intentional act that causes death, while passive euthanasia is seen as an intentional act to avoid prolonging the dying process. They maintain that the distinction between these two modes of euthanasia depends not on motive, but on means. (...) The authors present a theoretical discussion of which forms are justified and unjustified, and explore, with the help of case studies, four main perspectives on the issue: those of the individual, the family, the medical profession, and society as a whole. ISBN 0-8264-0470-7: $24.95. (shrink)

Christian health care professionals in our secular and pluralistic society often face uncertainty about the place religious faith holds in today's medical practice. Through an examination of a virtue-based ethics, this book proposes a theological view of medical ethics that helps the Christian physician reconcile faith, reason, and professional duty. Edmund D. Pellegrino and David C. Thomasma trace the history of virtue in moral thought, and they examine current debate about a virtue ethic's place in contemporary bioethics. Their (...) proposal balances theological ethics, based on the virtues of faith, hope, and charity, with contemporary medical ethics, based on the principles of beneficence, justice, and autonomy. The result is a theory of clinical ethics that centers on the virtue of charity and is manifest in practical moral decisions. Using Christian bioethical principles, the authors address today's divisive issues in medicine. For health care providers and all those involved in the fields of ethics and religion, this volume shows how faith and reason can combine to create the best possible healing relationship between health care professional and patient. (shrink)

At the end of the most violent century in human history, it is good to take stock of our commitments to human and other life forms, as well as to examine the rights and the duties that might flow from their biological makeup. Professor Thomasma and Professor Loewy have held a long-standing dialogue on whether there are moral differences between animals and humans. This dialogue was occasioned by a presentation Thomasma made some years ago at Loewy's invitation at (...) the University of Illinois, Peoria, Medical Center. During that presentation, Thomasma argued that human beings are sufficiently distinct from other animals genetically and otherwise to justify a moral difference in rights and obligations. In effect, he argued that there are species-specific rights. This essay will pick up the threads of that dialogue. (shrink)

Applying general and statistical knowledge to individuals is difficult either on epidemiological or epistemological grounds. This paper examines these difficulties from the perspective of computer registers of epidemiological data.

Ethics consults at a university medical center share many qualitites with those in other settings. What makes them different, if at all, is a difference of degree, not kind. All consult services share the tasks of exploring cases for possible recommendation, contributing to the development of institutional and public policy, and educating colleagues and patients about medical ethics dimensions. Nonetheless, the university setting, devoted as it is to teaching, research, and public service, brings a slightly different focus to these tasks (...) and adds other, peripheral ones. (shrink)

A detailed multi-disciplinary analysis of Sudan in the post-colonial era with a consideration of possibilities for the future.

As an introduction to this issue, I argue that the concept of autonomy is clearly important for many of the freedoms we enjoy. The problem in medicine with its use lies in interpreting the concept with respect to the impact of disease on persons, the models of medicine we employ, and the settings in which the problems arise. A short statement about the major points of the authors collected in this issue concludes the editorial.