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)
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)
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)
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)
: 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)
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 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(e.g., ``On average, 5 out of every 100 patientswill benefit'') can be confused with expressionsof uncertainty of the belief type (e.g.,``The chance that I will benefit is about80%''). 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)
Recent years have witnessed a growing concern that terminally illpatients are needlessly suffering in the dying process. This has ledto demands that physicians become more attentive in the assessment ofsuffering and that they treat their patients as `whole persons.'' Forthe most part, these demands have not fallen on deaf ears. It is nowwidely accepted that the relief of suffering is one of the fundamentalgoals of medicine. Without question this is a positive development.However, while the importance of treating suffering has generally (...) beenacknowledged, insufficient attention has been paid to the question ofwhether different types of terminal suffering require differnt responsesfrom health care professionals. In this paper we introduce a distinctionbetween two types of suffering likely to be present at the end of life,and we argue that physicians must distinguish between these types if theyare to respond appropriately to the suffering of their terminally illpatients. After introducing this distinction and explaining its basis,we further argue that the distinction informs a (novel) principle ofproportionality, one that should guide physicians in balancing theircompeting obligations in responding to terminal suffering. As weexplain, this principle is justified by reference to the intereststerminally ill patients have in restoration, as well as in therelief of suffering, at the end of life. (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)
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)
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)
