The literature on conscience in medicine has paid little attention to what is meant by the word ‘conscience.’ This article distinguishes between retrospective and prospective conscience, distinguishes synderesis from conscience, and argues against intuitionist views of conscience. Conscience is defined as having two interrelated parts: (1) a commitment to morality itself; to acting and choosing morally according to the best of one’s ability, and (2) the activity of judging that an act one has done or about which one is deliberating (...) would violate that commitment. Tolerance is defined as mutual respect for conscience. A set of boundary conditions for justifiable respect for conscientious objection in medicine is proposed. (shrink)

For decades, physicians, philosophers, theologians, lawyers, and the public considered brain death a settled issue. However, a series of recent cases in which individuals were declared brain dead yet physiologically maintained for prolonged periods of time has challenged the status quo. This signals a need for deeper reflection and reexamination of the underlying philosophical, scientific, and clinical issues at stake in defining death. In this paper, I consider four levels of philosophical inquiry regarding death: the ontological basis, actual states of (...) affairs, epistemological standards, and clinical criteria for brain death. I outline several candidates for the states of affairs that may constitute death, arguing that we should strive for a single, unified ontological definition of death as a loss of integrated functioning as a unified organism, while acknowledging that two states of affairs may satisfy this concept. I argue that the clinical criteria for determining whole-brain death should be bolstered to meet the epistemic demand of sufficient certainty in defining death by adding indicators of cerebro-somatic dis-integration to the traditional triad of loss of consciousness, loss of brainstem function, and absence of confounding explanations. (shrink)

Increasingly, physicians are being asked to provide technical services that many believe are morally wrong or inconsistent with their beliefs about the meaning and purposes of medicine. This controversy has sparked persistent debate over whether practitioners should be permitted to decline participation in a variety of legal practices, most notably physician-assisted suicide and abortion. These debates have become heavily politicized, and some of the key words and phrases are being used without a clear understanding of their meaning. In this essay, (...) I endeavor, firstly, to clarify the meaning of some of these terms: conscience, conscientious action, professional judgment, conscientious objection, conscience clauses, civil disobedience, and tolerance. I argue that use of the term conscientious objection to describe these refusals by health care professionals is mistaken and confusing. Secondly, relying on a proper understanding of the moral and technical character of medical judgment, the optimal deference that the state and markets ought to have toward professions, and general principles of Lockean tolerance for a diversity of practices and persons in a flourishing, pluralistic, democratic society, I offer a defense of tolerance with respect to the deeply held convictions of physicians and other health care professionals who hold minority views on contested but legal medical practices. (shrink)

The word ‘dignity’ is used in a variety of ways in bioethics, and this ambiguity has led some to argue that the term must be expunged from the bioethical lexicon. Such a judgment is far too hasty, however. In this article, the various uses of the word are classified into three serviceable categories: intrinsic, attributed, and inflorescent dignity. It is then demonstrated that, logically and linguistically, the attributed and inflorescent meanings of the word presuppose the intrinsic meaning. Thus, one cannot (...) conclude that these meanings are arbitrary and unrelated. This categorization and logical and linguistic analysis helps to unravel what seem to be contradictions in discourse about dignity and bioethics, and provides a hierarchy of meaning that has potential normative implications. (shrink)

One of the most important questions in the debate over the morality of euthanasia and assisted suicide is whether an important distinction between killing patients and allowing them to die exists. The U.S. Supreme Court, in rejecting challenges to the constitutionality of laws prohibiting physician-assisted suicide, explicitly invoked this distinction, but did not explicate or defend it. The Second Circuit of the U.S. Court of Appeals had previously asserted, also without argument, that no meaningful distinction exists between killing and allowing (...) to die. That court had reasoned that if this were so, it would be discriminatory to allow persons on life support to end their lives by removing such treatment, while those who are not connected to life support would be denied similar access to death. (shrink)

A number of practices at the end of life can causally contribute to diminished consciousness in dying patients. Despite overlapping meanings and a confusing plethora of names in the published literature, this article distinguishes three types of clinically and ethically distinct practices: double-effect sedation, parsimonious direct sedation, and sedation to unconsciousness and death. After exploring the concept of suffering, the value of consciousness, the philosophy of therapy, the ethical importance of intention, and the rule of double effect, these three practices (...) are defined clearly and evaluated ethically. It is concluded that, if one is opposed to euthanasia and assisted suicide, double-effect sedation can frequently be ethically justified, that parsimonious direct sedation can be ethically justified only in extremely rare circumstances in which symptoms have already completely consumed the patient’s consciousness, and that sedation to unconsciousness and death is never justifiable. The special case of sedation for existential suffering is also considered and rejected. (shrink)

While there has been much discussion about the role of oaths in medical ethics, this discussion has previously centered on the content of various oaths. Little conceptual work has been done to clarify what an oath is, or to show how an oath differs from a promise or a code of ethics, or to explore what general role oath-taking by physicians might play in medical ethics. Oaths, like promises, are performative utterances. But oaths are generally characterized by their greater moral (...) weight compared with promises, their public character, their validation by transcendent appeal, the involvement of the personhood of the swearer, the prescription of consequences for failure to uphold their contents, the generality of the scope of their contents, the prolonged time frame of the commitment, the fact that their moral force remains binding in spite of failures on the part of those to whom the swearer makes the commitment, and the fact that interpersonal fidelity is the moral hallmark of the commitment of the swearer. Oaths are also distinct from codes. Codes are collections of specific moral rules. Codes are not performative utterances. They do not commit future intentions and do not involve the personhood of the one enjoined by the code. Recent attacks on oath-taking by physicians are discussed. Two arguments in favor of oath-taking are presented: one on the basis of the nature of medicine as a profession and the other on the basis of rule-utilitarian considerations. No attempt is made to define which oath a physician should swear. (shrink)

The Rule of Double Effect has played an important role in bioethics, especially during the last fifty years. Its major application in bioethics has been in providing physicians who are opposed to euthanasia with a moral justification for using opioid analgesics in treating the pain of patients whose death might thereby be hastened. It has also prominently been applied to certain obstetric cases. The scope of application of double effect is actually much broader than medical ethics, extending to cover such (...) topics as strategic bombing in warfare. This article, while general in theory, concentrates on its applications in medical ethics. (shrink)

Pellegrino was there at the beginning of the field. In the 1950s and 60s, before there was a Kennedy Institute of Ethics or a Hastings Center; before the word ‘bioethics’ itself was coined, Pellegrino was writing articles such as "Ethical Considerations in the Practice of Medicine and Nursing," published in 1964. He was among those who started the Society for Health and Human Values—a precursor organization to the American Society for Bioethics and Humanities. He was the founding editor of the (...) Journal of Medicine and Philosophy at a time when the notion that there was a relationship between philosophy and medicine was foreign to both physicians and philosophers. The authors of the articles published in the very .. (shrink)

We thank Nielsen Busch and Mjaaland for their article on the dead donor rule (Nielsen Busch and Mjaaland 2023). We would like to take this opportunity to go beyond the dead donor rule in order to r...

David Thomasma called for the development of a medical ethics based squarely on the philosophy of medicine. He recognized, however, that widespread anti-essentialism presented a significant barrier to such an approach. The aim of this article is to introduce a theory that challenges these anti-essentialist objections. The notion of natural kinds presents a modest form of essentialism that can serve as the basis for a foundationalist philosophy of medicine. The notion of a natural kind is neither static nor reductionistic. Disease (...) can be understood as making necessary reference to living natural kinds without invoking the claim that diseases themselves are natural kinds. The idea that natural kinds have a natural disposition to flourish as the kinds of things that they are provides a telos to which to tether the notion of disease – an objective telos that is broader than mere survival and narrower than subjective choice. It is argued that while nosology is descriptive and may have therapeutic implications, disease classification is fundamentally explanatory. Sickness and illness, while referring to the same state of affairs, can be distinguished from disease phenomenologically. Scientific and diagnostic fallibility in making judgments about diseases do not diminish the objectivity of this notion of disease. Diseases are things, not kinds. Injury is a concept parallel to disease that also makes necessary reference to living natural kinds. These ideas provide a new possibility for the development of a philosophy of medicine with implications for medical ethics. (shrink)

The notion of the value of life is often invoked in discussions regarding medical care for the sick and the dying. This theme has figured in arguments about medical ethics for decades, but many of the phrases associated with this concept have received little serious scrutiny. It is true that some philosophers have declared a few commonly used phrases such as “the sanctity of life,” “the infinite value of life,” and “the value of life itself” to be unclear at best (...) or misguided at worst. Their hasty dismissal of these phrases, however, is not the end of the story. I generally agree with this philosophical judgment but for reasons very different from those typically given by others. Moreover, the reasons I wish to .. (shrink)

One major argument against prohibiting euthanasia and physician-assisted suicide (PAS) is that there is no rational basis for distinguishing between killing and allowing to die: if we permit patients to die by forgoing life-sustaining treatments, then we also ought to permit euthanasia and PAS. In this paper, the author argues, contra this claim, that it is in fact coherent to differentiate between killing and allowing to die. To develop this argument, the author provides an analysis of Saint Augustine’s distinction between (...) martyrdom and suicide, highlighting the relevance of intention in the assessment of an agent’s actions. As a general matter of ethics, the intentions of agents, not just the outcomes of their actions, matter enormously for drawing distinctions between what is permissible and what is impermissible. Constructing an Augustinian account of this distinction between killing and allowing to die, the author argues that it is coherent to hold that assisted suicide is wrong, while also accepting that it is permissible to withhold or withdraw life-sustaining treatments. (shrink)

Many states in the U.S. have adopted policies regarding human embryonic stem cell (hESC) research in the last few years. Some have arrived at these policies through legislative debate, some by referendum, and some by executive order. New York has chosen a unique structure for addressing policy decisions regarding this morally controversial issue by creating the Empire State Stem Cell Board with two Committees—an Ethics Committee and a Funding Committee. This essay explores the pros and cons of various policy arrangements (...) for making public policy decisions about morally controversial issues in bioethics (as well as other issues) through the lens of Deliberative Democracy, focusing on the principles of reciprocity, publicity, and accountability. Although New York's unique mechanism potentially offers an opportunity to make policy decisions regarding a morally controversial subject like hESC research in accord with the principles of Deliberative Democracy, this essay demonstrates its failure to do so in actual fact. A few relatively simple changes could make New York's program a real model for putting Deliberative Democracy into practice in making policy decisions regarding controversial bioethical issues. (shrink)

Media coverage and statements by various Catholic spokespersons regarding the case of Terri Schiavo has generated enormous and deeply unfortunate confusion regarding Church teaching about the use of life-sustaining treatments. Two weeks ago, for example, I received a letter from the superior of a community of Missionary Sisters of Charity, who operate a hospice here in the United States The Missionary Sisters of Charity are the community founded by Mother Theresa, the 20th Century saint whose primary ministry was to rescue (...) dying Untouch-ables from the streets of Calcutta and bring them into her convent where they were washed, sheltered, fed if they were able to eat, prayed for, and cherished. In other words, the sisters gave these poor souls the gift of a death with dignity. The order Mother Theresa founded has continued this ministry, running hospices in the United States and elsewhere for the homeless, the destitute, those dying of AIDS and poverty and drug addiction, and all those dying alone and otherwise unwanted. (shrink)

This article traces the history of the concept of dignity in Western thought, arguing that it became a formal Catholic theological concept only in the late nineteenth century. Three uses of the word are distinguished: intrinsic, attributed, and inflorescent dignity, of which, it is argued, the intrinsic conception is foundational. The moral norms associated with respect for intrinsic dignity are discussed briefly. The scriptural and theological bases for adopting the concept of dignity as a Christian idea are elucidated. The article (...) concludes by discussing the relevance of this concept of dignity to the spiritual and ethical care of the dying. (shrink)

The word ‘dignity’ arises continuously in the debate over euthanasia and assisted suicide, both in Europe and in North America. Unlike the phrases ‘autonomy’ and ‘slippery slope’, ‘dignity’ is used by those on both sides of the question. For example, the organizations most prominently associated with the campaign that culminated in the recent legalization of euthanasia in Belgium are the Association pour la Droit de Mourir dans la Dignité and Recht op Waardig Sterven. Yet when Belgium passed its euthanasia law, (...) that nation’s Catholic bishops declared, “All this is opposed to the fundamental respect for human life that lies at the heart of a society based on human dignity”. Or, consider the fact that the legislation that legalized assisted suicide in the state of Oregon, U.S.A., was called the “Death with Dignity Act.” Yet opponents of assisted suicide in the United States, such as the Family Research Council, have declared that, “The idea of assisted suicide is a poison pill that kills the dignity of a precious human life”.Over and above differences in translation, the word ‘dignity’ cannot mean the same thing in all four of the preceding sentences. It cannot be the univocal basis of moral arguments both for and against euthanasia and assisted suicide. A better understanding of this word would therefore help to bring clarity and insight to the arguments about euthanasia and assisted suicide in Europe, North America, and throughout the world. (shrink)

Pellegrino has argued that end-of-life decisions should be based upon the physician's assessment of the effectiveness of the treatment and the patient's assessment of its benefits and burdens. This would seem to imply that conditions for medical futility could be met either if there were a judgment of ineffectiveness, or if the patient were in a state in which he or she were incapable of a subjective judgment of the benefits and burdens of the treatment. I argue that a theory (...) of futility according to Pellegrino would deny that latter but would permit some cases of the former. I call this the circumspect view. I show that Pellegrino would adopt the circumspect view because he would see the medical futility debate in the context of a system of medical ethics based firmly upon a philosophy of medicine. The circumspect view is challenged by those who would deny that one can distinguish objective from subjective medical judgments. I defend the circumspect view on the basis of a previously neglected aspect of the philosophy of medicine -- an examination of varieties of medical judgment. I then offer some practical applications of this theory in clinical practice. (shrink)

Prestigious University is a large, private educational institution with a medical school, a university hospital, a law school, and graduate and undergraduate colleges all on a single campus. In the face of the Covid‐19 pandemic, students were told during spring break to return to campus only briefly to retrieve their belongings. Classes then went online. On March 23, 2020, the faculty, students, and staff were emailed the following by the university's director of infection control and public health: We have become (...) aware that a Prestigious University staff member has tested positive for the virus that causes Covid‐19. The individual, who was last on campus on March 16, is now in isolation at their permanent residence and is doing well clinically. The university has already identified those members of our community who may have been in close contact with this individual, and we are working to notify them. Further, this individual's local health department has a protocol for identifying people who have been in direct contact with anyone testing positive for Covid‐19 (such as this Prestigious University staff member) so that they can self‐quarantine and watch for COVID‐19 symptoms for a period of 14 days from their last contact with the infected individual.A professor in the Philosophy Department has asked the ethicists at the medical school whether such contact tracing suffices. “Don't the members of the community deserve to know who this is? Isn't there a mandate to identify this person in order to maximize public health benefits and slow the spread of this deadly virus?”. (shrink)

Health care has increasingly come to be understood as a commodity. The ethical implications of such an understanding are significant. The author argues that health care is not a commodity because health care (1) is non-proprietary, (2) serves the needs of persons who, as patients, are uniquely vulnerable, (3) essentially involves a special human relationship which ought not be bought or sold, (4) helps to define what is meant by necessity and cannot be considered a commodity when subjected to rigorous (...) conceptual analysis. The Oslerian conception that medicine is a calling and not a business ought to be reaffirmed by both the profession and the public. Such a conception would have significant ramifications for patient care and health care policy. (shrink)

Towards the end of the last century, bioethics underwent an “empirical turn,” characterized by an increasing number of empirical studies about issues of bioethical concern. Taking a cue from the evidence-based medicine movement, some heralded this as a turn toward evidence-based ethics. However, it has never been clear what this means, and the strategies and goals of evidence-based ethics remain ambiguous. In this article, the author explores what the potential aims of this movement might be, ultimately arguing that, while the (...) development of good empirical research can and should aid in ethical deliberation, one ought to avoid assuming or suggesting that empirical studies themselves determine normative prescriptions and proscriptions. The limits of the use of empirical studies in bioethics are explored in detail, and 10 potential ways that such studies can soundly contribute to bioethics are described. Good ethics depends upon sound facts, but ethics cannot be based on evidence alone. (shrink)

The ethical treatment of cancer patientsparticipating in clinical trials requiresthat patients are well-informed about thepotential benefits and risks associated withparticipation. When patients enrolled in phaseI clinical trials report that their chance ofbenefit is very high, this is often taken as evidence of a failure of the informed consent process. We argue, however, that some simple themes from the philosophy of language may make such a conclusion less certain. First, the patient may receive conflicting statements from multiple speakers about the expected (...) outcome of the trial. Patients may be reporting the message they like best. Second, there is a potential problem of multivocality. Expressions of uncertainty of the frequency type can be confused with expressionsof uncertainty of the belief type. Patients may be informed using frequency-type statements and respond using belief-type statements. Third, each speech episode involving the investigator and the patient regarding outcomes may subservemultiple speech acts, some of which may beindirect. For example, a patient reporting ahigh expected benefit may be reporting a beliefabout the future, reassuring family members,and/or attempting to improve his or her outcome by apublic assertion of optimism. These sources oflinguistic confusion should be considered injudging whether the patient's reported expectation isgrounds for a bioethical concern that there hasbeen a failure in the informed consent process. (shrink)

Dear Norm,Thank you for sharing such a personal and heartfelt essay. I have been asked by the editors to comment. Reading it inspires me to do so in a similarly heartfelt way. Although I don't know you well, I thought I'd write to you as if you were my patient.I share your sense that Alzheimer disease is a terrible scourge. I've seen much of this disease over a lifetime of practice, and I deeply understand its ravages and the debility and (...) suffering it causes. But what you propose is not a good solution for the problems that Alzheimer disease poses for patients, families, and society. It will ultimately do far more harm than good. Please let me try to explain. (shrink)

: On the grounds that rape is an act of violence, not a natural act of intercourse, Roman Catholic teaching traditionally has permitted women who have been raped to take steps to prevent pregnancy, while consistently prohibiting abortion even in the case of rape. Recent scientific evidence that emergency contraception (EC) works primarily by preventing ovulation, not by preventing implantation or by aborting implanted embryos, has led Church authorities to permit the use of EC drugs in the setting of rape. (...) Doubts about whether an abortifacient effect of EC drugs has been completely disproven have led to controversy within the Church about whether it is sufficient to determine that a woman is not pregnant before using EC drugs or whether one must establish that she has not recently ovulated. This article presents clinical, epidemiological, and ethical arguments why testing for pregnancy should be morally sufficient for a faith community that is strongly opposed to abortion. (shrink)

Francis W. Peabody, MDDepartment of MedicineBoston City Hospital and Harvard Medical SchoolBoston, MassachusettsMarch 19, 2017Dear Dr. Peabody,Thank you for giving us the opportunity to review your manuscript "The Care of the Patient." It has been carefully considered by the editors and two external reviewers. We regret to inform you that it cannot be considered further for publication in the Prestigious Journal of Medicine.Chief among our reasons is that it is overly long. Opinion pieces—especially non-data driven articles about topics like ethics—should (...) be no longer than 1,000 words. Compounding matters, the lack of graphics or tables makes the paper difficult to digest efficiently. We also agree with the... (shrink)

The idea that ethics can be derived from a common morality, while controversial, has become very influential in biomedical ethics. Although the concept is employed by several theories, it has most prominently been given a central role in principlism, an ethical theory endorsed by Tom Beauchamp and James Childress in Principles of Biomedical Ethics (2009).1 This text has become a cornerstone of medical ethics education, an achievement that has been commended by critics and supporters alike. It articulates a system of (...) ethical decision making that is firmly rooted in claims about the common morality. Beauchamp and Childress’s theory of common morality has been both defended and criticized in the bioethics .. (shrink)

Euthanasia and rational suicide were acceptable practices in some quarters in antiquity. These practices all but disappeared as Hippocratic, Jewish, Christian, and Muslim beliefs took hold in Europe and the Near East. By the late nineteenth century, however, a political movement to legalize euthanasia and physician-assisted suicide (PAS) began in Europe and the United States. Initially, the path to legalization was filled with obstacles, especially in the United States. In the last few decades, however, several Western nations have legalized euthanasia, (...) and several US jurisdictions have now legalized PAS, giving state sanction to these once forbidden practices. With increasing social and political pressure to accept PAS, Christians need to understand how to think about this issue from an explicitly Christian perspective. Independent of the question of legalization, there are significant theological and ethical questions. This special issue aims to address those concerns, including: how does the practice of PAS or euthanasia impact our attitudes toward death, and what does it mean to “die well?” Should physicians, as healers, be involved in assisting patients who wish to bring about their own death? Are these methods significantly distinguished from other ethically justified practices in end-of-life care that also lead to a person’s death? Can Christians, both as patients and practitioners, justify the use of these methods to relieve suffering in this manner as compatible with the faith? Although these questions are not new to the debate, it is increasingly important that these controversies are addressed as the practice of PAS is popularized. (shrink)

New Natural Law Theory and the Catholic medico-moral tradition often lead to similar conclusions in hard cases regarding end-of-life care. Considering the provision of artificial nutrition and hydration to patients suffering from post-coma unresponsive wakefulness, however, brings to light subtle ways in which NNL differs from the centuries-old natural law tradition. In this essay, I formalize the methodology embedded within the casuistry of the medico-moral tradition and show how it differs from NNL with respect to the role played by double-effect (...) reasoning and the perspective for analyzing cases regarding care for those who cannot speak for themselves. Importantly, the ordinary/extraordinary means distinction has never historically been understood as an application of double effect and logically cannot be so understood. Given the outsized role that double effect plays in NNL, the theory leads to conclusions that deviate from the Catholic medico-moral tradition and creates additional burdens and duties for the sick. (shrink)

My article, “Whole-brain death and integration: Realigning the ontological concept with clinical diagnostic tests”.

Shortly after the Presidential Commission for the Study of Bioethical Issues was constituted in 2010 and days before the commission members were to join a conference call to discuss possible topics for their deliberation, Craig Venter held a press conference announcing that his lab had created a synthetic chromosome for a species of mycoplasma and had inserted this genetic material into organisms of another species of mycoplasma (the genes of which had been deactivated), transforming the host species into the donor (...) species. While not overtly claiming to have “created life in the test tube,” Venter's publicity seemed cleverly designed to provoke the media into reporting his discovery in just that way. The resulting uproar caused President Obama to give his new bioethics commission the assignment of investigating the ethics of the emerging field of synthetic biology. The commission went right to work. It formed working groups to deliberate about parts of the report, feeding ideas and language to the staff members who would do the actual writing, and then present the working group suggestions to the commission as a whole for public deliberation at open meetings. One of those working groups was charged with coming up with ethical principles that would guide the analysis. Having served as a member of that working group, I report here on the process by which these principles emerged and reflect upon the suitability of that process for the work of public bioethics commissions. (shrink)