Catalogue of the Cleveland Museum of Art's photographic holdings.

The notion of patients’ duties has received periodic scholarly attention but remains overwhelmed by attention to the duties of healthcare professionals. In a previous paper the author argued that patients in publicly funded healthcare systems have a duty to participate in clinical research, arising from their debt to previous patients. Here the author proposes a greatly extended range of patients’ duties grounding their moral force distinctively in the interests of contemporary and future patients, since medical treatment offered to one patient (...) is always liable to be an opportunity cost in terms of medical treatment needed by other patients. This generates both negative and positive duties. Ten duties—enjoining obligations ranging from participation in healthcare schemes to promoting one’s own earliest recovery from illness—are proposed. The characteristics of these duties, including their basis, moral force, extent and enforceability, are considered. They are tested against a range of objections—principled, societal, epistemological and practical—and found to survive. Finally, the paper suggests that these duties could be thought to reinforce a regrettably adversarial characteristic, shared with rights-based approaches, and that a preferable alternative might be sought through the notion of a “virtuous patient” contributing to a problem-solving partnership with the clinician. However, in defining and giving content to that partnership, there is a clear role for most, if not all, of the proposed duties; their value thus extends beyond the adversarial context in which they might first be thought to arise. (shrink)

Patients participating in the shared benefits of publicly funded health care enjoy the benefits of treatments tested on previous patients. Future patients similarly depend on treatments tested on present patients. Since properly designed research assumes that the treatments being studied are—so far as is known at the outset—equivalent in therapeutic value, no one is clinically disadvantaged merely by taking part in research, provided the research involves administering active treatments to all participants. This paper argues that, because no other practical or (...) moral considerations count decisively against so doing, we could and should oblige patients to agree to receive indicated treatment within the terms of any concurrent research protocols. This ensures their treatment will benefit not only themselves but also future patients through contributing to new knowledge. By analogy with the paying of income tax, patients should not be allowed to “veto” their social responsibility to take part in clinical research. (shrink)

Using a fictional but representative general practice consultation, involving the diagnosis of irritable bowel syndrome in a patient who is anxious for some relief from the discomfort his condition entails, this paper argues that when both a drug fails to out-perform placebo and the condition in question is a functional illness with no demonstrable underlying pathology, then the action of the drug is not only no better than placebo, and it is also no different from it either. The paper also (...) argues that, in the circumstances of the consultation described, it is striking that current governance deems it ethical for a practitioner to prescribe either a drug or a placebo, both of which appear to rely for their effectiveness on a measure of concealment on the part of the doctor, yet deems it unethical for a practitioner openly to prescribe a harmless and enjoyable substance which is likely to be no less effective than either drug or placebo and is also likely to be better-tolerated and cheaper than the drug. (shrink)

While there may be a place in some contexts for high handed, “blanket” legislative prohibitions on dissenting views of what constitutes death, the paper under consideration does not describe such a contextThis stimulating and provocative paper by Professor Appel, Defining death: when physicians and families differ, asks us to consider “whether patients’ families should be permitted to opt out of widely accepted definitions of death in favour of their own standards”. This is a striking question in many ways. It reminds (...) us that, as a simple description of fact, there are indeed different standards for human death in so far as different groups or communities have accepted and continue to accept varying notions of what constitutes human death. The question’s reference to “opting out” suggests, perhaps reasonably, that it seems prima facie odd to think of adopting a definition of death as being a matter of individual choice. The reference to “permission” invites us to suppose limitations, primarily legal, upon the extent to which such a choice could be tolerated. Also, the question ascribes to certain “definitions of death” the authority of being widely accepted. The definitions thus favoured are, we learn, the various formulations of death referring to the state of the brain, chief among them “whole brain death” although the author is troublingly vague over whether all such formulations are morally, legally, or conceptually equivalent; and the relevant communities of acceptance turn out to consist of many—but, as the author admits, not all—physicians labouring under varying and inconsistent jurisdictions in the United States.My preface to the criticisms that follow is a …. (shrink)

Professors are increasingly encouraged to adopt multiple role relationships with their students. Regardless of professor intent, these relationships carry risks. Left unexamined is whether student–faculty social multiple relationships impact student in-class behaviors. Provocatively, our exploratory study provides empirical support suggesting that when undergraduate students perceive that their professors engage in the multiple faculty–student relationships of friendships, drinking relationships, and sexual partnerships, students report they are more likely to engage in uncivil behaviors in the professor’s classroom. Accordingly, our study provides a (...) backdrop against which to think more substantively about the professorial role and the boundaries that accompany it. (shrink)

Under higher education’s contemporary consumer model, students are treated as customers and professors are encouraged to increase student engagement through more personal out-of-class interactions, often in social settings. In the course of this more personal student-faculty involvement, students inevitably encounter or learn of their professors’ occasional inappropriate or unethical behavior. In the present study, we investigated the impact of 145 American undergraduate Business students’ perceptions of their professors’ inappropriate out-of-class behavior on student beliefs and in-class behavior. Results indicate that student (...) perceptions of professors engaging in inappropriate out-of-class behavior were associated with students viewing these professors as lower in ethical character and reporting a stronger likelihood of attending these professors’ classes under the influence of alcohol and illicit drugs, swearing and using vulgarity in these professors’ class discussions, and showing disregard for these professors’ rules, time, and effort. These relationships held even when student grade satisfaction and professor in-class behavior were accounted for. Our results suggest professors’ behavior outside the classroom may impact students’ behavior inside the classroom, re-igniting dialogue regarding the professorial role and the boundaries on oversight of that role. We offer suggestions as to how higher education may address these concerns without infringing upon professors’ personal freedoms. (shrink)

In terms of intervening in embodied experience, medical treatment is wonder-full in its ambition and its metaphysical presumption; yet, wonder’s role in clinical medicine has received little philosophical attention. In this paper, I propose, to doctors and others in routine clinical life, the value of an openness to wonder and to the sense of wonder. Key to this is the identity of the central ethical challenges facing most clinicians, which is not the high-tech drama of the popular conceptions of medical (...) ethics but, rather, the routine of patients’ undramatic but unremitting demands for the clinician’s time and respectful attention. Wonder (conceived as an intense and transfiguring attentiveness) is a ubiquitous ethical source, an alternative to the more familiar respect for rational autonomy, a source of renewal galvanizing diagnostic imagination, and a timely recalling of the embodied agency of both patient and clinician. (shrink)

In the UK, many fundamentally important policy decisions that are likely to affect the relationship between citizens and care services are now made at the sublegislative level and without adequate ethical consideration and scrutiny. This is well exemplified in the proposed guidance on the disclosure of information on children. A recent consultation paper by the UK government on the subject proposes an approach that seeks a simple technical solution to a complex problem, emphasising control and surveillance. This reflects pressure to (...) be seen to act. The document fails with regard to ethical reflection appropriate to the complexity of the issue, an appreciation of complex relationships of trust, and a proper sense of the richness and complexity of the public interest. Such policies would, if implemented, fundamentally change the relationships between citizens and their carers, and among carers and the law and the state. This and similar proposals require far more ethical scrutiny and consideration of the public interest in the widest sense. (shrink)

Is it possible to distinguish, as sociologist Arthur Frank proposes, an ‘ideal of wonder’ within which ill persons could recover some of their former sense of life and flourishing, even within the constraints of ill-health? Beyond this, are there more general benefits in terms of health and well-being that could accrue from cultivating an openness to wonder? In this paper I will first outline and defend a notion of wonder that gives philosophical support to Frank’s proposal, noting why thinking about (...) medical treatment may readily provoke a sense of wonder. Second I will however limit the normative force of such an ‘ideal of wonder’ noting its demands and some of the challenges facing it. The paper goes on, third, to conjecture wider benefits within and beyond the clinical encounter arising from being mindful of the wonder of embodied human agency. Fourth the paper will consider alignments between the foregoing analysis and some theoretical commitments in recent work in health geography. Finally I will briefly reconsider the notion of the body-as-territory, and the role of the imagination in bringing it under wonder’s gaze. (shrink)

The Gardner report, recently published in the UK, showing a correlation between incidence of childhood leukaemia and paternal exposure to ionising radiations (amongst fathers working in nuclear power plants) has added a new element to debates about both the risk factors in nuclear power plants and the relationships between ionising radiations and leukaemogenesis. The epidemiologic and genetic evidence concerning leukaemias is reviewed here and it is concluded that the leukaemogenic agent, whose existence is indicated in the Gardner report, is unlikely (...) to be paternal radiation dose per se but rather exposure to another factor that is correlated with paternal radiation dose received. (shrink)

This paper first distinguishes governance (collective, autonomous self-regulatory processes) from government (externally-imposed mandatory regulation); it proposes that the second of these is essentially incompatible with a conception of the medical humanities that involves imagination and vision on the part of medical practitioners. It next develops that conception of the medical humanities, as having three distinguishable aspects (all of them distinct from the separate phenomena popularly known as “arts-in-health”): first, an intellectual enquiry into the nature of clinical medicine; second, an important (...) dimension of medical education; third, a resource for moral and aesthetic influences upon clinical practice, supporting “humane health care” as the moral inspirations behind organised medicine. Medical humanities sustains these three aspects through paying proper attention to the existential and subjective aspects of medicine. By encouraging authentic imagination among health care practitioners, medical humanities aligns well with both humane health care and governance in the sense of self-regulation. However, it can neither be achieved mechanistically nor well-measured through proxies such as patient satisfaction. Above all, it should not be allowed to supply, through inappropriate qualitative “targets,” new forms of management tyranny. (shrink)

“Medical humanities” is a phrase whose currency is wider than its agreed meaning or denotation. What sort of study is it, and what is its relation to the study of philosophy of medicine? This paper briefly reviews the origins of the current flowering of interest and activity in studies that are collectively called “medical humanities” and presents an account of its nature and central enquiries in which philosophical questions are unashamedly central. In the process this paper argues that the field (...) of enquiry is well-conceived as being philosophical in character, and as having philosophy — albeit pursued over a larger canvas — at the core of its contributing humanities disciplines. The paper characterises humanities disciplines as having an important focus on human experience and subjectivity, of which the experiences and subjectivities at stake in health, medicine and illness form an important sub-set, the preoccupation of the medical humanities as a whole. Claims of interdisciplinarity (as distinct from multidisciplinarity) are noted, but such claims need to be recognised for the high and stern ambition that they embody, and should not be made lightly. (shrink)

Two well-recognised, but inherently reductionist, relations between medicine and music are the attempted neuro-scientific understanding of responses to music and interest in music’s contributions to clinical therapy. This paper proposes a third relation whereby music is seen as an organising metaphor for clinical medicine as a practice. Both music and clinical medicine affirm human well-being, and both do this inter alia through varieties of skilful, crafted yet spontaneous mutual engagement between a ‘performer’ and an ‘audience’. I argue that this organising (...) metaphor offers a corrective to the reductionist influences of the first two relations, illuminates a number of medicine’s important features, and reaffirms the existential as being at the core of medicine’s telos. (shrink)

Ted Shotter's founding of the London Medical Group 50 years ago in 1963 had several far reaching implications for medical ethics, as other papers in this issue indicate. Most significant for the joint authors of this short paper was his founding of the quarterly Journal of Medical Ethics in 1975, with Alastair Campbell as its first editor-in-chief. In 1980 Raanan Gillon began his 20-year editorship . Gillon was succeeded in 2001 by Julian Savulescu, followed by John Harris and Soren Holm (...) in 2004, with Julian Savulescu starting his second and current term in 2011. In 2000 an additional special edition of the JME, Medical Humanities , was published, under the founding joint editorship of Martyn Evans and David Greaves. In 2003 Jane Macnaughton succeeded David Greaves as joint editor. Deborah Kirklin, under whose auspices MH became an independent journal, took over in 2008, and she was succeeded in 2013 by Sue Eckstein. This short paper offers reminiscences and reflections from the two journals’ various editors.From the start the JME was committed to clearly expressed reasoned discussion of ethical issues arising from or related to medical practice and research. In particular, both Edward Shotter and Alastair Campbell, each a cleric , were at pains to make clear that the JME was not a religious journal and that it had no sort of partisan axe to grind.Campbell's appointment as founding editor was something of a surprise, as the original intention had been to appoint a medical doctor, who could be expected to know medical practice from the inside. However, in 1972 Campbell, a Joint Secretary of the Edinburgh Medical Group, had published Moral dilemmas in medicine. …. (shrink)

Buddhism originated and developed in an Indian cultural context that featured many first-person practices for producing and exploring states of consciousness through the systematic training of attention. In contrast, the dominant methods of investigating the mind in Western cognitive science have emphasized third-person observation of the brain and behavior. In this chapter, we explore how these two different projects might prove mutually beneficial. We lay the groundwork for a cross-cultural cognitive science by using one traditional Buddhist model of the mind (...) – that of the five aggregates – as a lens for examining contemporary cognitive science conceptions of consciousness. (shrink)

This book is the result of an idea launched by the present editors of providing a gift to Dr. Runner in the form of a Festschrift written by former students. The response was overwhelming. Glenn Andreas, one of Dr. Runner's closest friends, and Paul Schrotenboer, secretary of the Reformed Ecumenical Synod, enthusiastically joined us, together with Bernard Zylstra of the Institute for Christian Studies and Harry Van Dyke of the Free University of Amsterdam, to form a committee for this purpose... (...) Upon the appearance of this publication the editors wish to express their sincere thanks to the members of the committee for the advice and encouragement they gave and for the work they have done. (shrink)

Philosophy of mind has made substantial progress on biologically-rooted approaches to understanding the mind and subjectivity through the enactivist perspective, but research on subjectivity within neuroscience has not kept apace. Indeed, we possess no principled means of relating experiential phenomena to neurophysiological processes. Here, we present the Nested States Model as a framework to guide empirical investigation into the relationship between subjectivity and neurobiology. Building on recent work in phenomenology and philosophy of mind, we develop an account of experiential states (...) as layered, or nested. We argue that this nested structure is also apparent in brain activity. The recognition of this structural homology — that both experiential and brain states can be characterized as systems of nested states — brings our views of subjective mental states into broad alignment with our understanding of general principles and properties of brain activity. This alignment enables a more systematic approach to formulating specific hypotheses and predictions about how the two domains relate to one another. (shrink)

While functioning quite well for many years, the bioethics profession is in crisis. John H. Evans closely examines the history of the bioethics profession, and based on the sociological reasons the profession evolved as it did, proposes a radical solution to the crisis.

Tracing the history of American sociology since the Civil War, the authors of this important volume explain the field′s diversity, its lack of unifying paradigms, its broad, eclectic research agenda and its general weakness as an institutional force in either academia or the policy arena. They highlight the equivocal and often contradictory missions that sociologists prescribe for themselves and the variable nature of human, financial and intellectual resources available to the profession.

Bioethicists’ attraction to principlism is rooted in a Western view of how matters that affect the public ought to be deliberated and decided: their resolution ought to be so structured and constrained that it can be understood and verified even by those at a remove from the circumstances of the problem. That view of deliberation, itself fostered by the Western view of government, has encouraged principlism to spread from its source in human subjects research into other areas of bioethics discourse.