In lieu of an abstract, here is a brief excerpt of the content:Clinical Ethics: Balancing Praxis and TheoryEdmund D. Pellegrino (bio)When André Hellegers founded the Kennedy Institute, he envisioned a close collaboration between ethics and clinical practice. He even called for physician specialists whose expertise would be in both fields (Reich 1994, p. 324). A quarter of a century later, his vision and prediction have become realities. Clinical ethics is today a thriving entity with its own literature, practitioners, and methodology.This (...) clinical turn has, on the whole, been salutary. The abstractness of ethical theory has been tempered by the concreteness of clinical realities; clinicians have been helped to make bedside decisions even in the face of theoretical uncertainty and dissonance; and a variety of disciplines besides theology and philosophy have entered ethical discourse and enriched it.These advantages notwithstanding, clinical ethics has certain inherent traits that make it problematical. Some seek its norms in what “works” in practice or in paradigm cases (Jonsen and Toulmin 1988); others shape it to achieve consensus or satisfy the needs of public policy (Meilaender 1995); still others reduce bioethics to merely a method for the resolution of moral conflict. Rather than simply modulating theory by practice, clinical ethics can end up by repudiating theory entirely (Toulmin, in press). Taken to their logical conclusion, these tendencies make clinical ethics a species of the antifoundationalism that has strongly influenced moral philosophy in the last decade (Tollefsen 1995, pp. 3–18; Rockmore and Singer 1992). But antifoundationalism itself is a theory of ethics even though it supposedly denies the validity of any overarching theories.Antifoundationalism presents its own difficulties. For one thing it begs important questions that will not go away: for example, how do we know that a decision is a good one? what does it mean to say that a decision “works”? is the [End Page 347] outcome of a good decisional procedure itself a good decision? and to what extent are compromise and exigency admissible in moral decisions? Theoretical and “foundational” questions of this sort will not evaporate because they are ignored. They inevitably will be answered by begging the essential questions or grounding them solely in prelogical presuppositions.To avoid these difficulties, the advantages of clinical ethics must be retained without capitulation to the anti-theory bias of contemporary philosophy. This means that theory and practice must both be retained and be conceptually related to each other. To effect this we must take account of the long intellectual history of the relationship between the speculative and the practical intellect—i.e., between knowledge sought for its own sake and knowledge sought for some use beyond simply the possession of it (Lobkowicz 1967, pp. 78–81). Suffice it to say that medicine has long been the paradigm case for the union of theory and praxis. Relating them conceptually is an essential propaedeutic to any theory of moral praxis in medicine.The rest of this essay examines the inextricability of theory and practice in two of the three major branches of clinical ethics—the substantive and the professional. The third branch, procedural ethics—i.e., the ethics of the process of decision making—deals with informed consent, with respect for persons, professional colleagues, and families, and with the ethics of conflict resolution. Obviously, there are theoretical issues here as well. For want of space, procedural ethics will not be discussed, but it presents the same conjunction of theory and practice encountered in professional and substantive ethics.Substantive EthicsSubstantive ethics refers to the moral content rather than the process of moral decisions, to the moral status and permissibility of the specific clinical medical acts themselves—e.g., abortion, euthanasia, pre-implantation diagnosis, surrogate motherhood, withholding and withdrawing treatment, the physician as gatekeeper, and the like—the whole range of moral questions clinicians face in treating patients. Moral diversity and plurality on these issues is the most powerful force behind the dominance of procedural ethics. But, unfortunately, a morally valid decision-making procedure does not confer normative validity on the decision itself. Moral validity rests on questions that go beyond prevailing practices, on what we take to be the nature and moral status of persons, fetuses, and brain-damaged humans, the value or disvalue of... (shrink)

Mehlman and Massey examine possible legal responses to the issues that confront physicians faced with treating patients who have insufficient financial resources. This commentary explores the same issues from the perspective of ethics, including a comparison of the way law and ethics interpret the physician-patient relationship, the ethical obligations of physicians that are inherent in that relationship, and the propriety of Mehlman and Massey's legal and ethical proposals to ameliorate physicians' conflicting obligations in providing or withholding care on grounds of (...) conservation of society's resources. (shrink)

It is widely assumed that informing prospective subjects about the risks and possible benefits of research not only protects their rights as autonomous decisionmakers, but also empowers them to protect their own interests. Yet interviews with patient‐subjects conducted under the auspices of the Advisory Committee on Human Radiation Experiments suggest this is not always the case. Patient‐subjects often trust their physician to guide them through decisions on research participation. Clinicians, investigators, and IRBs must assure that such trust is not misplaced.

While uncertainty can never be totally eliminated from clinical practice, physicians can at least come to terms with it. In interviews with Canadian physicians in a variety of clinical settings, three sources of uncertainty affecting the allocation of medical resources were identified. Technical uncertainty arises from inadequate scientific data. Personal uncertainty arises from not knowing patients' wishes. Conceptual uncertainty arises from the problem of applying abstract criteria to concrete situations.

Frames of Deceit is a philosophical investigation of the nature of trust in public and private life. It examines how trust originates, how it is challenged, and how it is recovered when moral and political imperfections collide. In politics, rulers may be called upon to act badly for the sake of a political good, and in private life intimate attachments are formed in which the costs of betrayal are high. This book asks how trust is tested by human goods, moral (...) character and power relations. It explores whether an individual's experience of betrayal differs totally from that of a community when it loses and then seeks to recover a vital public trust. Although this is a work of political philosophy it is distinctive in examining three literary texts - Sophocles' Philoctetes, Shakespeare's Troilus and Cressida, and Zola's Thérése Raquin - in order to deepen our understanding of the place of trust in morality and politics. (shrink)

This combination textbook and anthology provides coverage of the fundamental topics in current medical ethics adn familiarizes the reader with the basic moreal and social issues confronting the medical profession today.

The central thesis of this paper is that cost-containment challenges to an Ideal Advocate model of the physician-patient relationship can be met under proper circumstances. More specifically, it is possible for physicians to constrain costs while still making clinical decisions that are free from considerations of the physician's own interests and are uninfluenced by judgements about the patient's worth. But what is required is a closed distributive system, in which savings of resources at one point are applied to others' care (...) of higher priority and a just system, that is, a system whose distributive priorities are consistent with relevant principles of justice under moderate scarcity. The historical context of the argument and a stopgap, palliative, step are also developed. (shrink)

The purpose of this study is to compare and contrast the basic ethical values underpinning national health care policies in the United States and Canada. We use the framework of ethical theory to name and elaborate ethical values and to facilitate moral reflection about health care reform. Section one describes historical and contemporary social contract theories and clarifies the ethical values associated with them. Sections two and three show that health care debates and health care systems in both countries reflect (...) the values of this tradition; however, each nation interprets the tradition differently. In the U.S., standards of justice for health care are conceived as a voluntary agreement reached by self-interested parties. Canadians, by contrast, interpret the same justice tradition as placing greater emphasis on concern for others and for the community. The final section draws out the implications of these differences for future U.S. and Canadian health care reforms. (shrink)