Our society has long sanctioned, at least tacitly, a degree of conflict of interest in medical practice and clinical research as an unavoidable consequence of the different interests of the physician or clinical investigator, the patient or clinical research subject, third party payers or research sponsors, the government, and society as a whole, to name a few. In the past, resolution of these conflicts has been left to the conscience of the individual physician or clinical investigator and to professional organizations. (...) The public is no longer willing to allow health care providers to wholly govern their own conflicts of interest for several reasons. These include: new forms of health care financing and delivery that provide innovative and lucrative opportunities for physician or insurer enrichment at patient expense; the increased importance of commercial research support as peer-reviewed governmental research support has decreased; evidence that physicians and clinical investigators too frequently resolve conflicts of interest in their own favor; and a general societal mistrust of authority. This volume represents a multidisciplinary effort, drawing from philosophy, medicine, law, economics and public policy to identify and categorize conflicts of interest in medical practice and clinical research, and, where possible, to offer a mechanism for resolving them. Part I addresses conflicts of interest from a theoretical perspective, offering basic concepts and analytical frameworks. The second part discusses two topics prominent in current health care policy debates--self-referral and financial incentives to limit care. Part III examines conflicts of interest generated by pharmaceutical industry involvement in clinical practice and research. The final section deals with conflicts of interest in clinical research in several contexts, including institutional reviews boards, clinical trials, Cooperative Research and Development Agreements between government and private researchers, brokerage of research subjects by Contract Research Organizations, and cost-effectiveness studies. (shrink)
Services of ethics consultants are nowadays commonly used in such various spheres of life as engineering, public administration, business, law, health care, journalism, and scientific research. It has however been maintained that use of ethics consultants is incompatible with personal autonomy; in moral matters individuals should be allowed to make their own decisions. The problem this criticism refers to can be conceived of as a conflict between the professional autonomy of ethics experts and the autonomy of the persons they serve. (...) This paper addresses this conflict and maintains that when the nature of both ethics consultation and individual autonomy is properly understood, the professional autonomy of ethics experts is compatible with the autonomy of the persons they assist. (shrink)
The emergence of the ethics consultation as a means to resolve moral crises in clinical medicine has revealed the need for a worksheet that would facilitate intake and analysis. The author developed the Bioethics Consultation Form as an attempt to remedy this need. The form is arranged in an outline format and is a useful asset to ethics committee discussions and record keeping. The first section covers basic intake data concerning the patient's medical and personal information, advance directives, (...) and values, as well as the values of the physician and family. After the intake section is completed with the above data, the ethics consultant then turns to the analysis section. This second section allows for (1) the discussion of conflicting values, (2) the identification of priorities, and (3) the elucidation of ethical norms relevant to the case.The Bioethics Consultation Form was adopted by the Patient Care Advisory committee of the Franklin Square Hospital Center in Baltimore, Maryland in 1986. The methodology in the use of the form will be discussed. Further, the potential spectrum of consultative cases that can be analyzed using the form will be highlighted. (shrink)
The importance of consulting with other professionals to maintain acceptable standards of care is well documented in many health care professions. However, evidence indicates that many psychologists fail to utilize consultation when needed, and that consultation use varies along dimensions such as the education and training of the consultee, the type of setting, number of years in practice, and proximity to available consultants. In this article, we review the research on the use of consultation by psychologists as (...) well as other health care professionals. We discuss the clinical, ethical, and legal implications of seeking consultation as a professional psychologist. Finally, a detailed and practical model for the regular use of consultation is given to improve the routine use of consultation in clinical practice. (shrink)
This paper is an exploration of a current environmental issue dividing two industries in the UK. The issue is offshore wind farms, and the industries are commercial fishing and wind energy. The controversy over offshore wind farms highlights three core issues of conflict: the adequacy of stakeholder consultation processes; the right to compensation for loss of livelihood; and the lack of adequate data. We find that the characterisations that developers, regulators, and fishers hold of each other critically inform their (...) positions on these issues. We examine the weak bargaining position of fishers, and the 'power game' that is played out between them and developers. We conclude that offshore wind farm development would be better managed if stakeholder consultation was more extensive, compensation claims were standardised, and scientific data were more readily available, but that in the meantime, fishers could improve their bargaining power by mobilising potential allies. (shrink)
The debate about what constitutes the discipline of ethics and who qualifies as an ethics consultant is linked unavoidably to a debate that is potentiated by the reality of a rapidly changing and high-stakes health care consultation marketplace. Who we are and what we can offer to the moral gesture that is medicine is shaped by our fundamental understanding of the place of expert knowledge in the transformation of social reality. The struggle for self-definition is particularly freighted since clinical (...) ethics consultation aspires to be more than academic contemplation. Two recent books (Ethics Consultation by John La Puma and David Schiedermayer and The Health Care Ethics Consultant: A Practical Guide, edited by Francoise Baylis) exemplify the two most popular but most widely divergent positions on these issues. We argue that while useful, neither book addresses fully the particular and distinct role of the professional ethicist. (shrink)
Central to much medical ethical analysis is the concept of the role of the physician. While this concept plays an important role in medical ethics, its function is largely tacit. The present paper attempts to bring the concept of a social role to prominence by focusing on an historically recent and rather richly contextured role, namely, that of consultation liaison psychiatry. Since my intention is primarily theoretical, I largely ignore the empirical studies which purport to develop the detailed functioning (...) of the role. My limited intent is to draw attention to the theoretical complexity of the consultation liaison role as an example of the general relevance of role concepts to medical ethics. For this reason, consultation liaison psychiatry will function as an illustration of fundamental concepts of medical ethics rather than as a subject of analysis in its own right. Similarly, the concept of the social role will be developed only as is necessary to explore the general relationship between the consultation liaison role and ethical analysis. Keywords: medical ethics, consultation liaison psychiatry, social role, autonomy, institution CiteULike Connotea Del.icio.us What's this? (shrink)
Previous papers on ethics consultation in medicine have taken a positivistic approach and lack critical scrutiny of the psychosocial, political, and moral contexts in which consultations occur. This paper discusses some of the contextual factors that require more careful research. We need to know more about what prompts and inhibits consultation, especially what factors effectively prevent house officers and nonphysicians from requesting consultation despite perceived moral conflict in cases. The attitudes and institutional power of attending medical staff (...) seem important, especially where innovative interventions raise ethical questions. Ethics consultants also need to address the thorny problems of the origin(s) of the consultant's authority, whistleblowing, conflicts of interest that affect the consultant, persistently poor communications in hospitals, systemic inequity in the availability or quality of services for some, and the standing of the consultant's recommendations, including their appearance in the patient's medical record. (shrink)
A new economic phenomenon, in which physicians refer their patients to ancillary facilities of which they themselves are owners or substantial investors, presents a ‘laboratory’ for assessing philosophers' potential contributions to public policy issues. In this particular controversy, ‘prohibitionists’ who wish to ban all such self-referral focus on the dangers that patients and payers may receive or be billed for unnecessary or poor-quality care. ‘Laissez-fairists’, in contrast, argue that self-referral should be freely permitted, with a reliance on personal (...) ethics and internal professional monitoring to guard against abuse. Undue government regulation, they argue, infringes providers' and patients' economic freedom, and stifles the competition that can yield better quality care at lower prices. As this debate features basic values and large amounts of money, it has been marked by rancorous rhetoric, shallow argument, and muddled reasoning. The philosopher's first contribution, therefore, is to expose simplistic and fallacious arguments, whether empirical, conceptual, moral, or legal. Beyond this, the philosopher can help to identify the important values at stake and, perhaps, to identify resolutions that honor those values better than the more simplistic answers proffered previously. For abusive self-referral, as distinguished from kickbacks, the author recommends that civil remedies be favored over criminal prohibitions. She suggests that the doctrine of ‘bad faith breach of contract’ might appropriately be extended into this new area to provide a powerful means by which aggrieved patients and payers can hold physicians personally accountable for abusive self-referrals. Keywords: bad faith breach of contract, civil law, criminal law, self-referral, simplistic reasoning CiteULike Connotea Del.icio.us What's this? (shrink)
A remarkable hypothesis has recently been advanced by Libet and promoted by Eccles which claims that there is standardly a backwards referral of conscious experiences in time, and that this constitutes empirical evidence for the failure of identity of brain states and mental states. Libet's neurophysiological data are critically examined and are found insufficient to support the hypothesis. Additionally, it is argued that even if there is a temporal displacement phenomenon to be explained, a neurophysiological explanation is most likely.
In September 2007, the Human Fertilisation and Embryology Authority (HFEA) in the United Kingdom concluded that "there is no fundamental reason to prevent cytoplasmic hybrid research . . . this area of research can, with caution and careful scrutiny, be permitted." Later, in January 2008, HFEA issued two research licenses to create humanesque cytoplasmic hybrid embryos from which stem cells could be derived. This article critically examines the public consultation process that preceded these decisions, concluding that the process was (...) flawed and demonstrating how the HFEA documents summarizing the findings of the public consultation process misrepresent the public's contributions to this policymaking initiative. (shrink)
Practices such as physician assisted suicide, even if legal, engender a range of moral conflicts to which many are oblivious. A recent proposal for physician assisted suicide provides an example by calling upon physicians opposed to suicide to refer patients to other, more sympathetic, physicians. However, the proposal does not address the moral concerns of those physicians for whom such referral would be morally objectionable. Keywords: collaboration, euthanasia, intrinsic evil, material cooperation, projects, referral, toleration CiteULike Connotea Del.icio.us What's (...) this? (shrink)
There is no doubt that emotions have an important effect on practices of moral reasoning such as clinical ethics consultation. Empathy is not only a basic human emotion but also an important and learnable skill for health care professionals. A basic amount of empathy is essential both in patient care and in clinical ethics consultation. This article debates the “adequate dose” of empathy in ethics consultations in clinical settings and tries to identify possible situations within the process of (...)consultation in which this crucial feeling is at risk. (shrink)
During the coming decades, life scientists will become involved more than ever in the public and private lives of patients and consumers, as health and food sciences shift from a collective approach towards individualization, from a curative to a preventive approach, and from being driven by desires rather than by technology. This means that the traditional relationships between the activities of life scientists – conducting research, advising industry, governments, and patients/consumers, consulting the public, and prescribing products, be it patents, drugs (...) or food products, information, or advice – are getting blurred. Traditional concepts of the individual, role, task, and collective responsibility have to be revised. This paper argues, from a pragmatic point of view, that the concept of public responsibility can contribute considerably in delineating new gray zones between the various roles of the life scientist: conducting research for governments or industry, giving advice, prescribing and selling products, and doing public consultation. The main issues are where new Chinese walls (not Berlin walls) need to be built between these activities, thereby increasing trust between life scientists and the public at large, and how to organize research agendas and to decide upon research topics. (shrink)
Of Goals and Goods and Floundering About: A Dissensus Report on Clinical Ethics Consultation Content Type Journal Article Pages 275-291 DOI 10.1007/s10730-009-9101-1 Authors Jeffrey P. Bishop, Vanderbilt University Center for Biomedical Ethics and Society 2525 West End Avenue, Suite 400 Nashville Tennessee 37203 USA Joseph B. Fanning, Vanderbilt University Center for Biomedical Ethics and Society 2525 West End Avenue, Suite 400 Nashville Tennessee 37203 USA Mark J. Bliton, Vanderbilt University Center for Biomedical Ethics and Society 2525 West End Avenue, (...) Suite 400 Nashville Tennessee 37203 USA Journal HEC Forum Online ISSN 1572-8498 Print ISSN 0956-2737 Journal Volume Volume 21 Journal Issue Volume 21, Number 3. (shrink)
IntroductionCultural Consultation is a clinical process that emerged from anthropological critiques of mental healthcare. It includes attention to therapeutic communication, research observations and research methods that capture cultural practices and narratives in mental healthcare. This essay describes the work of a Cultural Consultation Service (ToCCS) that improves service user outcomes by offering cultural consultation to mental health practitioners. The setting is a psychiatric service with complex and challenging work located in an ethnically diverse inner city urban area. (...) Following a period of 18 months of cultural consultation, we gather the dominant narratives that emerged during our evaluation of our service. Results: These narratives highlight how culture is conceptualized and acted upon in the day-to-day practices of individual health and social care professionals, specialist psychiatric teams and in care systems. The findings reveal common narratives and themes about culture, ethnicity, race and their perceived place and meaningfulness in clinical care. These narratives express underlying assumptions and covert rules for managing, and sometimes negating, dilemmas and difficulties when considering “culture” in the presentation and expression of mental distress. The narratives reveal an overall “culture of understanding cultural issues” and specific “cultures of care”. These emerged as necessary foci of intervention to improve service user outcomes. Conclusion: Understanding the cultures of care showed that clinical and managerial over-structuring of care prioritises organisational proficiency, but it leads to inflexibility. Consequently, the care provided is less personalised and less accommodating of cultural issues, therefore, professionals are unable to see or consider cultural influences in recovery. (shrink)
Living organ donation will soon become the source of the majority of organs donations for transplant. Should mentally handicapped people be allowed to donate, or should they be considered a vulnerable group in need of protection? I discuss three cases of possible living organ donors who are developmentally disabled, from three different cultures, the United States, Germany, and India. I offer a brief discussion of three issues raised by the cases: (1) cultural diversity and cultural relativism; (2) autonomy, rationality, and (...) self-interest; and (3) the proper use and role for clinical ethics consults. (shrink)
All over the world democratic reforms have brought power to the people-but under conditions where the people have little opportunity to think about the power that they exercise. Do we want a democracy inspired by Madison or by Madison Avenue? A democracy animated by deliberation or by manipulation? This book examines each of the principal democratic theories and makes the case for a democracy in which the people offer informed judgments about politics or policy. It then goes on to show (...) how this form of democracy can be made a reality. When the People Speak describes deliberative democracy projects conducted by the author with various collaborators in the US, China, Britain, Denmark, Australia, Italy, Bulgaria, Northern Ireland, and in the entire European Union. These projects have resulted in the massive expansion of wind power in Texas, the building of sewage treatment plants to China, the crafting of budget solutions in a region in Italy, and greater mutual understanding between Catholics and Protestants in Northern Ireland. The book is accompanied by a DVD of "Europe in One Room" by Emmy Award documentary makers Paladin Invision in London. The film recounts one of the most challenging deliberative democracy efforts with a scientific sample from 27 countries speaking 21 languages. -/- Critics of deliberative democracy say that it will privilege the more educated or that the public is incompetent when it comes to understanding policy issues, and should not be consulted. Others argue that it will increase polarization. Fishkin offers rebuttals for each of these arguments. Combining theory and practice he shows how a more deliberative politics is both practical and compelling. (shrink)
Taking organisational responses to the ?organ retention scandals? in the United Kingdom and Australia as a starting point, this paper considers the role of social welfare workers within the medico-legal system. Official responses to the inquiries of the late 1990s have focused on issues of consent and process-transparency, leaving unaddressed concerns expressed by the bereaved about the impact of organ retention on both their experience of grief and on the deceased themselves. A review of grief and embodiment literature suggests that (...) such concerns are consistent with the significance of relationship, attachment and identity within grief resolution?however that last problematic term is defined. The case example of an Australian coronial jurisdiction which has attempted to deal with some of these issues through mandating the discussion of autopsy and organ retention processes by grief counsellors with bereaved families is then provided. A distinction is drawn between these discussions and the seeking of consent. The discussion concludes by considering the ambiguous nature of the social welfare role within this contested field, suggesting that this ambiguity, while perhaps a source of flexibility in practice, may itself relate to a lack of clear information about the needs of the bereaved. This paper contributes to the development of that knowledge and offers some necessarily tentative recommendations regarding social welfare practice in this challenging arena. (shrink)
The obvious appeal and growing momentum of clinical ethics in academic medical centers should not blind us to a potential danger: the collapse of critical distance. The very integration into the clinical milieu and the processes of clinical decision making, that clinical ethics claims as its greatest success, carries the seeds of a dilution of ethics' critical stance toward medicine and medical education. The purpose of this paper is to suggest how this might occur, and what potential contributions of ethics (...) to medicine might be sacrificed as a result. Medical sociology will be used for comparison. Sociologists have found that they may function either as students and critics of established medical practices and educational philosophies, or as collaborative participants in them — but rarely both. It may be that professional ethics is most effective when it plays the role of stranger rather than insider, and is continually able to question the most basic assumptions and values of the enterprise with which it is associated. As with medical sociology, ethics and humanities must ask to what extent their desire for acceptance in the clinic requires their acceptance of the clinic: specifically, acceptance of basic assumptions about optimal ways of organizing medical education, socializing physicians-in-training, providing care, and even of defining medical ethics itself. The paper concludes by recommending that ethics reassert its strangeness in the medical milieu even as it assumes a more prominent role within the medical center. (shrink)
Observations with respect to the relationship between symptoms and diseases can seriously be biased by selection phenomena. This selection may occur from the general population, via consultation behavior, diagnostic and therapeutic activities of the general practitioner, and by referral.Relationships may be suggested and reproduced even if they do not exist in unselected populations, as a product of diagnostic routines. Correction for selection bias can only be achieved by choosing proper comparison (...) groups. While this can be done in a general practice setting, this is almost impossible after referral, as is demonstrated in this paper. Surprisingly, the most unbiased estimation of the relationship between symptoms and diseases after referral can be made from patient groups that are referred for reason unrelated to the disease under study. (shrink)
The document starts The overall goal proposed here is to construct physically instantiated systems that can perceive, understand, and interact with their environment - but also evolve in order to achieve human-like performance in activities requiring context-specific knowledge. I posted the following comment on 15 Feb 2006..
The practice of psychology in rural areas offers unique challenges for psychologists as they try to provide optimal care, often with a minimum of resources. Psychologists are frequently required to be creative and flexible in order to provide effective services to a wide range of clients. However, these unique challenges often confront psychologists with ethical dilemmas and problems for which their urban-based training has not prepared them. The author examines how certain characteristics of rural communities may lead to specific ethical (...) dilemmas. By being a part of a small community, psychologists will inevitably face multiple relationship dilemmas. Confidentiality is harder to maintain in a small town, particularly with its informal information-sharing network. To provide services to meet community needs, with a limited number of referral options, psychologists typically need to be generalists. This may lead to concerns about scope of practice, training, and experience with diverse populations. Psychologists also face other competency issues, such as a lack of supervision and consultation resources. Other concerns addressed include the psychologist's visibility in the community, having clients know about the psychologist's personal life, and the blurring of professional and personal roles. Suggestions are made for coping with each of these ethical issues, although more quantitative research and discussion are needed on the practice of psychology in rural areas. (shrink)
Clinical ethics committees have recently been established in nearly all Norwegian hospital trusts. One important task for these committees is clinical ethics consultations. This qualitative study explores significant barriers confronting the ethics committees in providing such consultation services. The interviews with the committees indicate that there is a substantial need for clinical ethics support services and, in general, the committee members expressed a great deal of enthusiasm for the committee work. They also reported, however, that tendencies to evade moral (...) disagreement, conflict, and 'outsiders' are common in the hospitals. Sometimes even the committees comply with some of these tendencies. The committees agree that there is a need to improve their routines and procedures, clarify the committees' profile and field of responsibility, to make the committees well-known, to secure adequate operating conditions, and to develop organizational integration and support. Various strategies to meet these challenges on a local, regional or national level are also explored in this paper. (shrink)
In summary, the usual elements of a typical health care ethics consultation note might reasonably accommodate the needs and expectations of relevant parties, and would therefore include: 1. identification of the relevant ethical issues, questions, or dilemmas; 2. reference to any relevant facts--medical, nursing, social, psychological, spiritual, legal, political, etc.; 3. a prioritized list of recommendations to improve coordinated care; 4. a clear and concise articulation of relevant arguments, wtih specific reference to the list of recommendations as well as (...) to the institution's overall ethos; 5. a contextual statement, identifying the perceived degree of consensus or support for the recommendations and conclusions, as well as any inherent agendas. (shrink)
In the clinical setting, questions of medical ethics raise a host of perplexing problems, often complicated by conflicting perspectives and the need to make immediate decisions. In this volume, bioethicists and physicians provide a nuanced, in-depth approach to the difficult issues involved in bioethics consultation. Addressing the needs of researchers, clinicians, and other health professionals on the front lines of bioethics practice, the contributors focus primarily on practical concerns -- whether ethics consultation is best done by individuals, teams, (...) or committees how an ethics consult service should be structured the need for institutional support and techniques and programs for educating and training staff -- without neglecting more theoretical considerations, such as the importance of character or the viability of organizational ethics. (shrink)
The article examines reasons and features of the Italian bioethics movement in itself and in relationship to that in the U.S.A. Research, consultation, teaching are the most requested professional activities. Ethics committees are now established in several places and at different level: national (National Italian Committee for Bioethics), regional (Italy has about twenty regions with some political power), and institutional (research centers, university, main hospitals).
Psychologists live in a globalizing world where traditional boundaries are fading and, therefore, increasingly work with persons from diverse cultural backgrounds. The Universal Declaration of Ethical Principles for Psychologists provides a moral framework of universally acceptable ethical principles based on shared human values across cultures. The application of its moral framework in developing codes of ethics and reviewing current codes may help psychologists to respond ethically in a rapidly changing world. In this article, a model is presented to demonstrate how (...) to use the Universal Declaration as a guide for creating or reviewing a code of ethics. This model may assist psychologists in various parts of the world in establishing codes of ethics that will promote global understanding and cooperation while respecting cultural differences. The article describes the steps involved in the application of the model and provides concrete examples as well as several useful comments and suggestions. This guide for the application of the Universal Declaration may also be used for consultation, education, and training relative to the Universal Declaration of Ethical Principles for Psychologists. (shrink)
Free and informed consent is generally acknowledged as the legal andethical basis for living organ donation, but assessments of livingdonors are not always an easy matter. Sometimes it is necessary toinvolve psychosomatics or ethics consultation to evaluate a prospectivedonor to make certain that the requirements for a voluntary andautonomous decision are met. The paper focuses on the conceptualquestions underlying this evaluation process. In order to illustrate howdifferent views of autonomy influence the decision if a donor's offer isethically acceptable, three (...) cases are presented – from Germany, theUnited States, and India. Each case features a person with questionabledecision-making capacity who offered to donate a kidney for a siblingwith severe renal insufficiency. Although the normative framework issimilar in the three countries, different or sometimes even contraryarguments for and against accepting the offer were brought forward. Thesubsequent analysis offers two explanations for the differences inargumentation and outcome in spite of the shared reference to autonomyas the guiding principle: (1) Decisions on the acceptability of a livingdonor cannot simply be deducted from the principle of autonomy but needto integrate contextual information; (2) understandings of the wayautonomy should be contextualized have an important influence on theevaluation of individual cases. Conclusion: Analyzing the conceptualassumptions about autonomy and its relationship to contextual factorscan help in working towards more transparent and better justifieddecisions in the assessment of living organ donors. (shrink)
An extended examination of Libet's works led to a comprehensive reinterpretation of his results. According to this reinterpretation, the Minimum Train Duration of electrical brain stimulation should be considered as the time needed to create a brain stimulus efficient for producing conscious sensation and not as a basis for inferring the latency for conscious sensation of peripheral origin. Latency for conscious sensation with brain stimulation may occurafterthe Minimum Train Duration. Backward masking with cortical stimuli suggests a 125-300 ms minimum value (...) for the latency for conscious sensation of threshold skin stimuli. Backward enhancement is not suitable for inferring this latency. For determining temporal relations between stimuli that correspond to subjects' reports, theendof cerebral Minimum Train Duration should be used as reference, rather than its onset. Results of coupling peripheral and cortical stimuli are explained by a latency after the cortical Minimum Train Duration, having roughly the same duration as the latency for supraliminal skin stimuli. Results of coupling peripheral stimuli and stimuli to medial lemniscus (LM) are explained by a shorter LM latency and/or a longer peripheral latency. This interpretation suggests a 230 ms minimum value for the latency for conscious sensation of somatosensory near-threshold stimuli. The backward referral hypothesis, as formulated by Libet, should not be retained. Long readiness potentials preceding spontaneous conscious or nonconscious movements suggest that both kinds of movement are nonconsciously initiated. The validity of Libet's measures of W and M moments (Libet et al., 1983a) is questionable due to problems involving latencies, training, and introspective distinction of W and M. Veto of intended actions may be initially nonconscious but dependent on conscious awareness. (shrink)
The Law Commission for England and Wales has published for consultation a proposal for an offence of first degree murder. A person found guilty of this offence whether as a principal or an accomplice will receive a mandatory sentence of life imprisonment. It is argued that the conditions for liability as an accomplice put forward by the Commission do not fulfil the Commission's aspiration for a "parity of culpability" between principals and accomplices. The discussion has general implications for the (...) reform of complicity laws. (shrink)
This article reviews the historical and current controversies about the nature of clinical ethics consultation, as a way to focus on the place and responsibility of ethics consultants within the context of clinical conversation — interpreted as a form of dialogue. These matters are approached through a particularly compelling instance of the controversy that involves several major figures in the field. The analysis serves to highlight very significant questions of the nature and constraints of clinical situations, and the moral (...) responsibility and legal accountability that are especially important for clinical ethics consultants. (shrink)
Four prominent views of the nature and methods of clinical ethics (especially in consultation forums) are reviewed; each is then submitted to a criticism intended to show both weaknesses and strengths. It is argued that clinical ethics needs to be responsive to the specific complexities of clinical situations. For this, the need for an expanded notion of practical reason within unique situations is emphasized, one whose aim is to facilitate decision-making on the part of those directly responsible for them (...) and consonant with their own respective moral frameworks and conceptions of what is most worthwhile. Keywords: Casuistry, clinical ethics, consultation, decision-making, dialogue, facilitator, practical reason, relationships CiteULike Connotea Del.icio.us What's this? (shrink)
The ballot is, as often said, a substitute for bullets. But what is more significant is that counting of heads compels prior recourse to methods of discussion, consultation and persuasion, while the essence of appeal to force is to cut short resort to such methods. Majority rule, just as majority rule, is as foolish as its critics charge it with being. But it never is merely majority rule.There have been two distinguished critics who declare great admiration for Dewey's work (...) and yet are constrained to say they find it essentially defective. Both Morton White and Charles L. Stevenson have reluctantly judged that Dewey's ethical theory fails at decisive points.In this paper, I argue that many recent interpretations .. (shrink)
In this paper we discuss expected and reported effects on care provider-patient relations of the introduction of electronic patient records (EPRs) in consultation settings by reviewing exemplary studies and literature on the subject from the past decade. We argue that in order for such assessments to be meaningful, talk of effects of “the” EPR needs to be replaced by an “unpacking” of EPR systems into their constituent parts and functionalities, the effects of which need to be assessed individually. Following (...) from this principle, the paper discusses EPR systems ranging from simple data entry and retrieval systems to more sophisticated multi-user and multifunctional on-line systems. On a second level, our analysis of the literature is informed by the question which model of ideal patienthood underlies the assessment of effects of EPRs. To this end, we identify three “models of patienthood” implicit in writing about benefits and drawbacks of EPRs for patients: the autonomy, the consumer, and the holistic models, and argue that assumptions concerning these models need to be reflected upon more critically to improve understanding of what exactly EPR use does to the doctor-patient relationship. (shrink)
The relationship between social segregation and workplace segregation has been traditionally studied as a one-way causal relationship mediated by referral hiring. In this paper we introduce an alternative framework which describes the dynamic relationships between social segregation, workplace segregation, individualsâ homophily levels, and referral hiring. An agent-based simulation model was developed based on this framework. The model describes the process of continuous change in composition of workplaces and social networks of agents, and how this process affects levels of (...) workplace segregation and the segregation of social networks of the agents (people). It is concluded that: (1) social segregation and workplace segregation may co-evolve even when hiring of workers occurs mainly through formal channels and the population is initially integrated (2) majority groups tend to be more homophilous than minority groups, and (3) referral hiring may be beneficial for minority groups when the population is highly segregated. (shrink)
In this article, consultation via the Internet and the use of the Internet as a source of medical information is examined from an ethical point of view. It is argued that important ethical aspects of the clinical interaction, such as dialogue and trust will be difficult to realise in an Internet-consultation. Further, it is doubtful whether an Internet doctor will accept responsibility. However, medical information via the Internet can be a valuable resource for patients wanting to know more (...) about their disease and, thus, it is a means to enhancing their autonomy. (shrink)
The legitimacy of clinical ethics consultation is often implied to rest on the legitimacy of moral expertise. In turn, moral expertise seems subject to many serious critiques, the success of which implies that clinical ethics consultation is illegitimate. I explore a number of these critiques, and forward “ethics expertise,” as distinct from “moral expertise,” as a way of avoiding these critiques. I argue that “ethics expertise” succeeds in avoiding most of the critiques, captures what clinical ethics consultants might (...) justifiably do, and expresses a subject matter which can be taught and assessed. (shrink)
Is bioethics consultation a profession? Withfew exceptions, the arguments andcounterarguments about whether healthcareethics consultation is a profession haveignored the historical and cultural developmentof professions in the United States, the wayssocial changes have altered the work andboundaries of all professions, and theprofessionalization theories that explain howmodern societies institutionalize expertise inprofessions. This interdisciplinary analysisbegins to fill this gap by framing the debatewithin a larger theoretical context heretoforemissing from the bioethics literature. Specifically, the question of whether ethicsconsultation is a profession is (...) examined fromthe perspectives of trait theory, Wilensky''sfive-stage process of professionalization,Abbott''s interdependent system of professions,and Haug''s deprofessionalization thesis. Whilehealthcare ethics consultation does not meetthe criteria to claim professional status,neither could most professions pass these idealtheoretical standards. Instead of a yes or nodichotomous response to the question, it ismore helpful to envision a professionalizationcontinuum with sales clerks or carpenters atone end and medicine or law at the other. During the past decade healthcare ethicsconsultation has been moving along thiscontinuum toward greater professional status. (shrink)
Xenotransplantation, or the use of animal cells, tissues and organs for humans, has been promoted as an important solution to the worldwide shortage of organs. While scientific studies continue to be done to address problems of rejection and the possibility of animal-to-human virus transfer, socio-ethical and legal questions have also been raised around informed consent, life-long monitoring, animal welfare and animal rights, and appropriate regulatory practices. Many calls have also been made to consult publics before policy decisions are made. This (...) paper describes the Canadian public consultation process on xenotransplantation carried out by the Canadian Public Health Association in an arm’s length process from Health Canada, the ministry overseeing government health policy and regulation. Focusing on six citizen fora conducted around the country patterned after the citizen jury deliberative approach, the paper describes the citizen panelists’ recommendations to hold off on proceeding with clinical trials and the rationales behind this recommendation. The consultation process is discussed in the context of constructive technology assessment, a framework which argues for broader input into earlier stages of technology innovation, particularly at the technology design stage. (shrink)
Participants (62 students from 6 doctoral programs in professional psychology) were given 3 ethical dilemmas, asked to generate their own solutions, and asked to make judgments about a number of provided alternatives. Students were asked either to make decisions after seeking consultation or to make decisions independently of consultation. There were few significant between-group differences along a number of dimensions including participants' ratings of acceptability of provided alternatives and levels of certainty, justification, and satisfaction with personally generated solutions. (...) For one of the vignettes, individuals using consultation, when compared with the control group, were significantly more likely to prefer their own solution to that of provided alternatives. The study was viewed as a needed first step in investigating a cherished assumption in clinical practice. (shrink)
This paper examines the ethical issues of conflict of interest raised by the burgeoning development of physician involvement in for-profit entrepreneurial activities outside their practice. After documenting the nature and extent of these activities, and their potential for conflicts of interest, the paper assesses the major arguments for and against physicians' referral of patients to facilities they own or in which they invest. The paper concludes that an outright ban on such activity seems ethically warranted.
This paper examines the ethical andsocial questions that underlie the present UKdiscussion whether GM crops and organicagriculture can co-exist within a given regionor are mutually exclusive. A EuropeanCommission report predicted practicaldifficulties in achieving sufficientseparation distances to guarantee lowerthreshold levels proposed for GM material inorganic produce. Evidence of gene flow betweensome crops and their wild relatives has beena key issue in the recent Government consultation toconsult on whether or not to authorizecommercial planting of GM crops, following theresults of the current (...) UK farm scale trials.The admixture of imported Bt transgenes intolandrace varieties of Mexican maize alsopresents difficulties. An ethical evaluationis made of the claim that organic growersshould expect protection from adventitioustraces of GM constructs in their products. Towhat extent – on either side of the debate –can any particular group in society set upagricultural standards for itself that mayeffectively restrain others from an otherwisejust business? The assumptions behind notionslike ``purity'' and ``contamination'' areexamined, together with their underlying viewsof nature and human intervention. The 2001UK Agriculture and Environmental BiotechnologyCommission report is relevant to theseissues. While the Government wishes to promotethe UK biotechnology industry and is underpressure from US claims of trade restraint, astrong organic lobby demands purity from GMcontamination. Does this adversarial framingof the issues reflect broader public opinionin the UK public consultation? Inarriving at policy decisions, the role of thevirtue of tolerance is considered inpost-modern and Christian ethical contexts. (shrink)
Accessing legislation via the Internet is more and more frequent. As a result, systems that allow consultation of law texts are becoming more and more powerful. This paper presents DARES, a generic system which can be adapted to any domain to handle documents production needs. It is based on an annotation engine which allows obtaining XML documents inputs as required by the system, and on an XML fragments recombining system. The latter operates using a fragment manipulation functions toolbox to (...) generate new documents. To validate this system, we have tried to apply it to the domain of law through the consolidation problem. (shrink)
The debate and implementation of Clinical Ethics Consultation (CEC) is still in its beginnings in Europe and the issue of the patient's perspective has been neglected so far, especially at the theoretical and methodological level. At the practical level, recommendations about the involvement of the patient or his/her relatives are missing, reflecting the general lack of quality and practice standards in CEC. Balance of perspectives is a challenge in any interpersonal consultation, which has led to great efforts to (...) develop technical approaches, e.g., in psychological counseling or psychotherapeutic treatment. In ethics, unbalance or partiality is a matter of justice and has provoked significant theoretical work, also relevant for practical medical ethics. A lack of balance seems to be particularly serious in those situations, where ethical conflict is triggering a consultation and where the parties involved may try to persuade the consultant that their particular opinion is the most convincing; but to our knowledge the connection between patient/relatives involvement and balance has not yet been discussed in the context of CEC. Central questions of access and involvement of the patient and his/her relatives will be analysed and discussed regarding the challenge of balance and the adequate role or attitude of a Clinical Ethics Consultant. It is argued that the Clinical Ethics Consultant should have a methodological awareness regarding the concepts of neutrality versus advocacy in his/her role and try to achieve a balanced procedure that allows for an optimum of change of perspectives. The argumentation is developed along the narrative of a real case study. Recommendations concerning the involvement of (the perspectives of) the patient or the relatives are formulated for the practice of CEC. (shrink)
Large-scale transnational land acquisition of agricultural land in the global south by rich corporations or countries raises challenging normative questions. In this article, the author critically examines and advocates a human rights approach to these questions. Mutually reinforcing, policies, governance and practice promote equitable and secure land tenure that in turn, strengthens other human rights, such as to employment, livelihood and food. Human rights therefore provide standards for evaluating processes and outcomes of transnational land acquisitions and, thus, for determining whether (...) they are ethically unacceptable land grabs. A variety of recent policy initiatives on the issue have evoked human rights, most centrally through the consultation and negotiation of the Voluntary Guidelines on the Responsible Governance of Tenure of Land, Fisheries and Forests concluded in 2012. However, a case of transnational land appropriation illustrates weak host and investor state enforcement of human rights, leaving the parties to in interaction with local groups in charge of protecting human rights. Generally, we have so far seen limited direct application of human rights by states in their governance of transnational land acquisition. Normative responses to transnational land acquisition—codes of conduct, principles of responsible agricultural investment or voluntary guidelines—do not in themselves secure necessary action and change. Applying human rights approaches one must therefore also analyze the material conditions, power relations and political processes that determine whether and how women and men can secure the human rights accountability of the corporations and governments that promote large-scale, transnational land acquisition in the global south. (shrink)
In this article we describe our approach to understanding wrongdoing in medical research and practice, which involves the statistical analysis of coded data from a large set of published cases. We focus on understanding the environmental factors that predict the kind and the severity of wrongdoing in medicine. Through review of empirical and theoretical literature, consultation with experts, the application of criminological theory, and ongoing analysis of our first 60 cases, we hypothesize that 10 contextual features of the medical (...) environment (including financial rewards, oversight failures, and patients belonging to vulnerable groups) may contribute to professional wrongdoing. We define each variable, examine data supporting our hypothesis, and present a brief case synopsis from our study that illustrates the potential influence of the variable. Finally, we discuss limitations of the resulting framework and directions for future research. (shrink)
Against the usual paternalism, this article develops the proposition to structure the interaction between the doctor and the patient as an inter-subjective consultation. This means that the "information" of the patient prior to treatment, when "informed consent" is secured, as well as the actual medical treatment would have to be turned into an interaction between two responsible individuals. The "irresponsibility" of this patient, which is supposed to result from his "uninformedness", as is often argued in favour of keeping to (...) paternalism, does not have to lead to an interaction model of prescription and compliance. Even for the interaction with patients who are unable to understand or consent, the concept of dialogical interaction must be maintained counterfactually; it has only to be supplemented by the variant of "tutorial action". The prescriptive model of behaviour is extended by the obligationâeven when the doctor is the sole decision makerâof acting in the well-understood self-interest of the patient and, if necessary, of providing evidence for this orientation of the treatment. Thus, the model of dialogical interaction is shown to be the comprehensive model, because it covers the interests of the doctor and of the patient. (shrink)
For the inaugural session of the Consultation on Mysticism and Politics at the 1995 convention of the College Theology Society, the consultation’s conveners, David Hammond and Kris Willumsen (both of Wheeling Jesuit College) organized a panel presentation on John Milbank’s Theology and Social Theory: Beyond Secular Reason. The panelists were John Berkman (then of Sacred Heart University, now of the Catholic University of America), Anthony Godzieba (VillanovaUniversity), Paul Lakeland (Fairfield University), and William Loewe (Catholic University of America).The choice (...) of text was a fortunate one as panelists and audience members alike recognized something emphasized by previous reviewers of the book: no matter how one evaluates Milbank’s proposal, he makes a major contribution to contemporary theology by plunging theology into the thick of the contemporary debates over the status of modernity and postmodernity. In doing so, Milbank avoids employing any of the means normally used in these debates, such as the correlationmethod. Rather, his deeply reflective analysis reaches back into the Christian theological tradition in order to retrieve its Augustinian moment for the post-Nietzschean present. From his dialogue with contemporary Western culture and the social and political theories which undergird it, Milbank pointedly proposes a provocation: not only an alternative theological reading of the history and status of modernity/postmodernity, but also nothing less than a truly theological reconstruction of the contemporary.This review symposium presents the panelists’ contributions, which have been revised for this publication. (shrink)
