Before asking what U.S. bioethics might learn from a more comprehensive and more nuanced understanding of Islamic religion, history, and culture, a prior question is, how should bioethics think about religion? Two sets of commonly held assumptions impede further progress and insight. The first involves what “religion” means and how one should study it. The second is a prominent philosophical view of the role of religion in a diverse, democratic society. To move beyond these assumptions, it helps to view religion (...) as lived experience as well as a body of doctrine and to see that religious differences and controversies should be welcomed in the public square of a diverse democratic society rather than merely tolerated. (shrink)
We argue that a turn toward virtue ethics as a way of understanding medical professionalism represents both a valuable corrective and a missed opportunity. We look at three ways in which a closer appeal to virtue ethics could help address current problems or issues in professionalism education—first, balancing professionalism training with demands for professional virtues as a prerequisite; second, preventing demands for the demonstrable achievement of competencies from working against ideal professionalism education as lifelong learning; and third, avoiding temptations to (...) dismiss moral distress as a mere “hidden curriculum” problem. As a further demonstration of how best to approach a lifelong practice of medical virtue, we will examine altruism as a mean between the extremes of self-sacrifice and selfishness. (shrink)
As the debate over how to manage or discourage physicians? financial conflicts of interest with the drug and medical device industries has become more heated, critics have questioned or dismissed the concept of ?conflict of interest? itself. A satisfactory definition relates conflict of interest to concerns about maintaining social trust and distinguishes between breaches of ethical duty and temptations to breach duty. Numerous objections to such a definition have been offered, none of which prevails on further analysis. Those concerned about (...) conflicts of interest have contributed to misunderstandings, however, by failing to demonstrate when social arrangements leading to temptations to breach duties are in themselves morally blameworthy. Clarifying ?conflict of interest? is important if we are eventually going to develop productive modes of engagement between medicine and for-profit industry that avoid the serious ethical pitfalls now in evidence. (shrink)
The definition of ‘medical humanities’ may be approached via three conceptions—the humanities as a list of disciplines, as a program of moral development, and as a supportive friend. The conceptions are grounded by linking them to three narratives—respectively, the history of the modern liberal arts college; the history of Petrarch and the studia humanitatis of the early Renaissance; and the life of Sir William Osler. The three conceptions are complementary, each filling gaps in one or more of the others. Getting (...) clearer on a definition of ‘medical humanities’ is practically important if this field is to take its rightful place within health professions education and practice. (shrink)
Bioethics' interdisciplinary base -- Patient-centered care -- Evidence-based medicine and pay-for-performance -- Community dialogue -- Overview : bioethics, power, and learning to see -- Cross-cultural concerns -- Race and health disparities -- Disabilities -- Environmental and global issues -- New technologies -- Conclusion.
The doctrine of clinical equipoise is appealing because it appears to permit physicians to maintain their therapeutic obligation to offer optimal medical care to patients while conducting randomized controlled trials (RCTs). The appearance, however, is deceptive. In this article we argue that clinical equipoise is defective and incoherent in multiple ways. First, it conflates the sound methodological principle that RCTs should begin with an honest null hypothesis with the questionable ethical norm that participants in these trials should never be randomized (...) to an intervention known to be inferior to standard treatment. Second, the claim that RCTs preserve the therapeutic obligation of physicians misrepresents the patient-centered orientation of medical care. Third, the appeal to clinical equipoise as a basic principle of risk-benefit assessment for RCTs is incoherent. Finally, the difficulties with clinical equipoise cannot be resolved by viewing it as a presumptive principle subject to exceptions. In the final sections of the article, we elaborate on the non-exploitation framework for the ethics clinical research and indicate issues that warrant further inquiry. (shrink)
*The opinions expressed are the views of the author and do not necessarily reflect the policy of the National Institutes of Health, the Public Health Service, or the U.S. Department of Health and Human Services.
: The "difference position" holds that clinical research and therapeutic medical practice are sufficiently distinct activities to require different ethical rules and principles. The "similarity position" holds instead that clinical investigators ought to be bound by the same fundamental principles that govern therapeutic medicine—specifically, a duty to provide the optimal therapeutic benefit to each patient or subject. Some defenders of the similarity position defend it because of the overlap between the role of attending physician and the role of investigator in (...) a research trial. This overlap is maximal when the same physician occupies both roles with respect to a particular patient-subject. We address the ethical tensions inherent in that role conflict and argue that the tensions are real but manageable. The difference position provides a sound ethical framework within which to manage those tensions, while the similarity position is unsatisfactory because it seeks to deny the existence of the tensions. (shrink)
The leading ethical position on placebo-controlled clinical trials is that whenever proven effective treatment exists for a given condition, it is unethical to test a new treatment for that condition against placebo. Invoking the principle of clinical equipoise, opponents of placebo-controlled trials in the face of proven effective treatment argue that they (1) violate the therapeutic obligation of physicians to offer optimal medical care and (2) lack both scientific and clinical merit. We contend that both of these arguments are mistaken. (...) Clinical equipoise provides erroneous ethical guidance in the case of placebo-controlled trials, because it ignores the ethically relevant distinction between clinical trials and treatment in the context of clinical medicine and the methodological limitations of active-controlled trials. Placebo controls are ethically justifiable when they are supported by sound methodological considerations and their use does not expose research participants to excessive risks of harm. (shrink)
A basic question of medical ethics is whether the norms governing medical practice should be understood as the application of principles and rules of the common morality to medicine or whether some of these norms are internal or proper to medicine. In this article we describe and defend an evolutionary perspective on the internal morality of medicine that is defined in terms of the goals of clinical medicine and a set of duties that constrain medical practice in pursuit of these (...) goals. This perspective is developed by means of a critical examination of the essentialist conception of the internal morality of medicine advocated by Edmund Pellegrino and the critique of internal morality approaches by Robert Veatch and Tom Beauchamp. (shrink)
Cosmetic surgery is a fast-growing medical practice. In 1997 surgeons in the United States performed the four most common cosmetic procedures443,728 times, an increase of 150% over the comparable total for 1992. Estimated total expenditures for cosmetic surgery range from $1 to $2 billion. As managed care cuts into physicians' income and autonomy, cosmetic surgery, which is not covered by health insurance, offers a financially attractive medical specialty.
The physician in Erde's clinical case study performed poorly in a number of aspects of informed consent and good physician-patient communication. However, the patient also failed to perform some of his own duties to participate in effective communication and so shares at least some responsibility for the bad outcome.
Among those who criticize the concept of a common refrain is that we really have no idea what futility means. For example, physicians seem to disagree on whether a treatment being futile means that it has a less than 5% chance of working or a 20% chance of working. If the concept is so unclear, then it seems a thin reed upon which to base a momentous ethical decision—namely, that the physician's judgment should be allowed to override the wishes of (...) the competent patient or the patient's duly appointed surrogate. (shrink)
Some ethical issues facing contemporary medicine cannot be fully understood without addressing medicine's internal morality. Medicine as a profession is characterized by certain moral goals and morally acceptable means for achieving those goals. The list of appropriate goals and means allows some medical actions to be classified as clear violations of the internal morality, and others as borderline or controversial cases. Replies are available for common objections, including the superfluity of internal morality for ethical analysis, the argument that internal morality (...) is merely an apology for medicine's traditional power and authority, and the claim that there is no single, "core" internal morality. The value of addressing the internal morality of medicine may be illustrated by a detailed investigation of ethical issues posed by managed care. Managed care poses some fundamental challenges for medicine's internal morality, but also calls for thoughtful reflection and reconsideration of some traditionally held moral views on patient fidelity in particular. (shrink)
Family medicine has grown as a specialty from its early days of general practice. It was established as a Board Certified specialty in 1969. This growth and maturation can be traced in the philosophy of family medicine as articulated by Edmund D. Pellegrino, M.D. Long before it was popular to do so, Pellegrino supported the development of family medicine. In this essay I examine the development of Pellegrino's philosophical thought about family practice, and contrast it to other thinkers like Ian (...) McWhinney, Kerr White, Walter Spitzer, Donald Ransom, and Hebert Vandervoort. The arguments focus on whether the goals of family medicine and family practice (possibly two distinct entities) can be articulated, especially considering the definitional problems of family and community. I conclude by echoing Pellegrino's hope that family medicine can contribute a fresh alternative to isolated, individualistic and technological thinking in medicine. (shrink)
Knight has shown how the moral growth of medical students involves a spiritual journey. He may, however, present too sanguine a portrayal of the extent to which the medical education environment promotes this moral and spiritual growth. Medical school may indeed be more abusive than supportive. Admitting more women to medical school and teaching more humanities courses, while worthwhile, will not necessarily promote the goals that Knight appropriately advocates.
We surveyed selected physician members of the Society for Health and Human Values (SHHV) to study the benefits and problems of combining a medical career with a strong scholarly interest in the humanities. The 19 usable narrative responses characterized major benefits as experiential base and teaching opportunities. Barriers were numerous and fell under the general headings of: lack of time; lack of institutional rewards; lack of money for research and scholarship; lack of support from humanities peers; lack of suport from (...) medical colleagues; personal financial sacrifice; and lack of training. Some respondents offered creative solutions to these problems, including assertive negotiation of a job description, identification of helpful mentors, and various networking and administrative strategies. The survey results, while preliminary, suggest ways in which SHHV can assist clinicians who wish to develop a serious commitment to humanities study and teaching. (shrink)
Froom and Froom all attention to referral bias as a frequent cause for misinterpreting the medical literature. This is particularly a source of false certainty, and therefore false science, in U.S. practice, where referral centers are often seen as the only legitimate source of medical knowledge and where primary care is discounted as a source of scientific observations. Appreciation of the primary care setting is therefore a critical element in theoretical understanding of medical epistemology.
A case-study, small-group-discussion (“focal problem”) exercise in the history of medicine was designed, piloted, and evaluated in an overseas course and an on-campus elective course for medical students. Results suggest that this is a feasible approach to teaching history of medicine which can overcome some of the problems often encountered in teaching this subject in the medical curriculum.