A "wrongful life" suit is based on the purported tortious liability of a genetic counsellor towards an infant with hereditary defects, with the latter asserting that he or she would not have been born at all if not for the counsellor's negligence. This negligence allegedly lies in the failure on the part of the defendant adequately to advice the parents or to conduct properly the relevant testing and thereby prevent the child's conception or birth. This paper will offer support for (...) the thesis that it would be both feasible and desirable to endorse "wrongful life" compensation actions. The genetic counsellor owed a duty of due professional care to the impaired newborn who now claims that but for the counsellor's negligence, he or she would not have been born at all. The plaintiff's defective life constitutes a compensable injury. A sufficient causal link may exist between the plaintiff's injury and the defendant's breach of duty of due professional care and an appropriate measure of damages can be allocated to the disabled newborn. Sanctioning a "wrongful life" cause of action does not necessarily entail abandoning valuable constraints with regard to abortion and euthanasia. Nor does it inevitably lead to an uncontrolled slide down a "slippery slope". (shrink)

This study investigates the impact of fraud/lawsuit revelation on U.S. top executive turnover and compensation. It also examines potential explanatory variables affecting the executive turnover and compensation among U.S. fraud/lawsuit firms. Four important findings are documented. First, there was significantly higher executive turnover among U.S. firms with fraud/lawsuit revelation in the Wall Street Journal than matched firms without such revelation. Second, although on average, U.S. top executives received an increase in cash compensation after fraud/lawsuit revelation, this increase is smaller than (...) that of matched non-fraud/lawsuit firms. Third, fraud/lawsuit firms were more likely to change top executive when chief executive officer (CEO) was not the board chairman and CEO had been on the board for a short time. Fourth, fraud/lawsuit firms were more likely to reduce their executive cash compensation when profitability was low, firms were involved in fraud, the compensation committee size was small, and the board met more often. These findings indicate that although, in general, U.S. fraud/lawsuits firms did not reduce their executive cash compensation, those involved in fraud were more likely to reduce their executive cash compensation than to change their top executives. The finding, that ethical standards is not a significant factor for U.S. executive turnover nor compensation reduction, suggests that ethics appears to play no part in the board’s decisions, and that U.S. firms may have ethical standards in writing but they do not implement nor enforce the standards. (shrink)

The recent Canadian lawsuit on patent infringement, filed by the Children’s Hospital of Eastern Ontario, has engendered a significant public debate on whether patenting genes should be legal in Canada. In part, this public debate has involved the use of social networking sites, such as Twitter. This case provides an opportunity to examine how Twitter was used in the context of this gene patent controversy.

Physicians have long served as expert witnesses in litigation, and their medical knowledge can contribute to the appropriate resolution of a case. However, ethical issues may arise when physicians appear on behalf of the tobacco industry. Two ways that doctors participate in lawsuits are through depositions and by testifying in court during trial. The Tobacco Deposition and Trial Testimony Archive is an electronic database of depositions, trial testimony, opening and closing statements, and other material from tobacco lawsuits collected (...) by the Center for Tobacco Use Prevention and Research. At the time the research for this article was conducted, the database included depositions and trial testimony of expert witnesses from 232 smoking and health cases. (shrink)

Hastings Center Report, Volume 52, Issue 5, Page 4-5, September–October 2022.

In this interfaith and multicultural fable, eloquent representatives of all members of the animal kingdom—from horses to bees—come before the respected Spirit King to complain of the dreadful treatment they have suffered at the hands of humankind. During the ensuing trial, where both humans and animals testify before the King, both sides argue their points ingeniously, deftly illustrating the validity of both sides of the ecology debate. The ancient antecedents of this tale are thought to have originated in India, with (...) the first written version penned in Arabic sometime before the 10th century in what is now Iraq. Much later, this version of the story was translated into Hebrew in 14th century France and was popular in European Jewish communities into the late 19th and early 20th centuries. This exquisite English translation, illustrated with 12 original color illumination plates, is useful in introducing young and old alike to environmental and animal rights issues. (shrink)

This article reports and analyses a ‘wrongful life’ lawsuit brought against a genetic counsellor who failed to refer a woman for prenatal genetic testing despite her pleas to do so; this resulted in the wrongful birth of a child with a genetic abnormality. As a result of negligence, the mother did not have a termination and the baby was born. This is an event that reveals the troublesome nature of prenatal genetic testing applications in medical practice in Korea. The case (...) presentation and critique illuminates how genetic research and its applications in practice influence human life and society. The central issues involved in the lawsuit are the discrepancies between present practice and the law, and lack of respect for the client’s request to make self-determined reproductive choices. The lawsuit is explored in terms of the ethical grounds for the court’s ruling, the responsibility of the genetic counsellor, the sociocultural impact of genetic testing in Korean society, and people’s ability to make informed choices about how this technology is applied in medical practice. (shrink)

The statements of physicians who serve as expert witnesses for the tobacco industry reveal subtle but significant problems. Some expert testimony obfuscates the important issues, and some initially reasonable statements later evolve into extreme positions during cross-examination. Such statements fall into a “gray area” of professional ethics, potentially misleading juries and adversely affecting professional integrity. Medical associations can and should strongly enforce professional standards that do not tolerate tobacco industry influence on physician expert witnesses.

A major strategy in the creation of sustainable economies is the establishment of alternative market institutions, such as fair trade and local market systems. However, the dynamics of these alternative markets are poorly understood. What are the rules of behavior by which these markets function? How do these markets maintain their separate identity as “alternative”: apart from the conventional (“free”) market system? Building on Lyson’s notion of civic agriculture, we argue that alternative markets maintain themselves through civic engagement. However, we (...) argue that the civically-engaged practices of alternative markets are poorly understood. We seek, therefore, to begin a conversation about the everyday forms of civic engagement in alternative practice and to do this we introduce a few useful conceptual tools. Building upon ideas in science studies about the collaboration of scientists (Hess, Alternative pathways in science and industry, 2007) we argue that civic markets have their own “market fields” and “modes of governance” (Bulkeley et al., Environment and Planning A 39:2733–2753, 2007), their own fields of social interaction in which rules of behavior become stabilized and determine how the market works. The creation of a social field also requires the demarcation of boundaries, referred to in the science studies literature as “boundary work” (Gieryn, Cultural boundaries of science: Credibility on the line, 1999). We apply the idea of boundary work to understand how alternative market actors maintain boundaries between alternative and conventional markets. Finally, studies of collaboration in science have often centered on the object created through these interactions, an object that is partially material and partially a product of knowledge, what (Rheinberger, Toward a history of epistemic things: Synthesizing proteins in the test tube, 1997) calls an “epistemic object.” We use this idea to understand that the creation of alternative objects of exchange, such as organic food, are epistemic objects in that they combine both particular materialities and particular ways of knowing. Using these concepts, we will carry out a close analysis of the mode of governance in the national organic market, looking specifically a recent governance crisis in organic agriculture known as the Harvey lawsuit. (shrink)

Adapted from Chan's (2000) model depicting success of litigation, this paper argues that with the application of various legislation, health maintenance organizations' (HMOs') violations of service fairness to each group: enrollees, physicians, and hospitals give rise to each group's lawsuits against the HMOs. Various authors (Bowen et al., 1999; Seiders and Berry, 1998) indicate that justice concepts such as distributive, procedural, and interactional justice can be applied to the area of service fairness. The violation of these underlying justice principles (...) with HMOs' service unfairness to enrollees, physicians, and hospitals is examined. A general synopsis of the ethical issues in the managed care industry is provided. The various lawsuits launched by each group: enrollees, physicians, and hospitals together with the key statutes used are discussed. This paper also highlights the provisions and ramifications of the 11 April 2000 landmark agreement that Aetna made with Texas Attorney General John Cornyn to settle the 1998 lawsuit brought against the company. Lastly, the current ethical issues in the managed care industry are further discussed. The value of this paper can be adapted to the study of organizations' service fairness violations in other industries or in the educational, governmental, and not-for-profit sectors both nationally and internationally. (shrink)

Lawsuits alleging illegal and unethical insurance sales practices have received widespread publicity in recent years. Although many observers have argued that one source of ethical conflicts for insurance agents is the industry's reliance on straight commission compensation, there remains a paucity of empirical data to support the claim. Therefore, we tested whether different forms of compensation influence insurance agent recommendations of products. We obtained survey responses from 336 insurance agents. Respondents were presented with a composite sketch of a hypothetical (...) client. Following this description, they were asked to identify which one of eight specified life insurance products they would recommend to the client. A between-groups design was employed to manipulate differences in compensation associated with the eight products. Results indicated that neither amount of coverage nor type of coverage (term life versus cash value) recommended was associated with compensation. However, an unanticipated finding was that amount of coverage recommended was significantly higher when the insured was male than when the insured was female. (shrink)

Malpractice lawsuits serve as a great source of pain, consternation and loss for physicians and patients alike, usually leaving all parties involved in the process with a sense of betrayal. A significant number of physicians will be sued at least once in their career, especially if they practice in some of the more vulnerable specialties. In addition, there is some evidence that the threat of malpractice lawsuits changes the practice style of many physicians, leading to the practice of (...) “defensive medicine” and raises the total cost of health care. Clearly, the prevention of medical malpractice is an issue that deserves considerable attention from physicians and from those who train them.Empirical evidence suggests that medical negligence may play a relatively minor role in malpractice lawsuits. As demonstrated by Localio, et al., one in thirty-five cases of negligence or incompetence actually results in a lawsuit. (shrink)

Malpractice lawsuits serve as a great source of pain, consternation and loss for physicians and patients alike, usually leaving all parties involved in the process with a sense of betrayal. A significant number of physicians will be sued at least once in their career, especially if they practice in some of the more vulnerable specialties. In addition, there is some evidence that the threat of malpractice lawsuits changes the practice style of many physicians, leading to the practice of (...) “defensive medicine” and raises the total cost of health care. Clearly, the prevention of medical malpractice is an issue that deserves considerable attention from physicians and from those who train them.Empirical evidence suggests that medical negligence may play a relatively minor role in malpractice lawsuits. As demonstrated by Localio, et al., one in thirty-five cases of negligence or incompetence actually results in a lawsuit. (shrink)

This paper examines the lawsuits brought by state and local government entities against prescription opioid producers and sellers. It examines their potential liability as well as some of the defenses they might raise. The paper also discusses multidistrict litigation and government lawsuits in state court. It concludes that litigation is not the best solution to the opioid crisis.

Over 200 lawsuits were filed against the Hertz rental car company by former customers who were arrested as a result of the company’s poor inventory control system and its implementation of two business practices which led to the filing of unsubstantiated stolen car reports with police. According to a whistleblower, these practices essentially meant Hertz was using police “as a repo company and the court system as a collection company” (News Nation 2022, 4:24). Consequences to the individuals who were (...) falsely charged with theft included financial hardship, job loss, reputational damage, child custody problems, the trauma of arrest sometimes at gunpoint, and the traumatic experience of being jailed. This case study calls for students to analyze the company’s actions from the perspectives of ethical theories and decision making, as well as corporate social responsibility. (shrink)

Terminally ill patients in 10 states plus Washington, D.C. have the right to take prescribed medications to end their lives (medical aid in dying). But otherwise-eligible patients with neuromuscular disabilities (ALS and other illnesses) are excluded if they are physically unable to “self-administer” the medications without assistance. This exclusion is incompatible with disability rights laws that mandate assistance to provide equal access to health care. This contradiction between aid-in-dying laws and disability rights laws can force patients and clinicians into violating (...) one or the other, potentially creating an underclass of patients denied medical care that is available to those with other (less physically disabling) terminal illnesses. The immediacy of this issue is demonstrated by a lawsuit in Federal court filed in August 2021, requesting assistance in self-administration for terminally ill patients with neuromuscular diseases. This paper discusses the background of this conflict, the ethical issues at the heart of the dilemma, and recommends potential remedies. (shrink)

Class action lawsuits and the justice that they are supposed to enforce have become of great concem to legislators in recent years. The traditional ruIes of tort liability cannot completely support the court decisions that have been reached. The rulings, however, are clearly in the interest of giving victims the justice that they are due. Legal scholars, such as Jules Coleman, claim that the conflicts between tort liability and class action justice cannot be reconciled in our legal system. I (...) propose an avenue of analysis whereby the principles of justice that support tort law are preserved as needed for modem issues, yet at the same time address the genuine public policy concems in these class actions. (shrink)

Drug recalls and lawsuits against pharmaceutical manufacturers are accompanied by announcements emphasizing harmful drug side-effects. Those with elevated health anxiety may be more reactive to such announcements. We evaluated whether health anxiety and financial incentives affect subjective symptom endorsement, and objective outcomes of cognitive and physiological functioning during a mock drug recall. Hundred and sixty-one participants reported use of over-the-counter pain medications and presented with a fictitious medication recall via a mock Food and Drug Administration website. The opportunity to (...) join a class-action lawsuit was manipulated. We assessed health anxiety, recalled drug usage, blood pressure, heart rate, and performance on a computerized Trail Making Test. Symptom endorsement was strongly predicted by health anxiety. When combined, three health anxiety measures explained 28.5% variance. These effects remain strong after controlling for depression and anxiety. Litigation condition did not predict symptom endorsement. Blood pressure and heart rate were modestly predicted by health anxiety, but not by litigation condition. TMT performance was consistently predicted by health anxiety, with higher scores associated with poorer performance. Although there were no main effects for litigation, interactions consistently emerged for the TMT, with generally poorer performance for those with higher health anxiety in the non-litigation condition; whereas health anxiety was unrelated to performance for the litigation condition. All but one participant joined the litigation when given the opportunity, despite a healthy sample and minimal use of pain medication. Subsequent data from 67 individuals with no mention of the FDA scenario or litigation showed that health anxiety still significantly predicts symptom endorsement, but the explained variance is less than half that obtained in the FDA scenario. The findings suggest that health anxiety plays a significant role in adverse symptom reporting, beyond anxiety or depression, and this effect is independent of the presence of the FDA recall. The lack of differences for health anxiety and symptom endorsement between litigation and non-litigation conditions rules out malingering. Although it is general practice in drug recalls to list potential adverse side effects caused by medications, this may elicit unintended symptom experiences and health anxious individuals may be more susceptible. (shrink)

Professor Fletcher challenges the traditional account of the development of tort doctrine as a shift from an unmoral standard of strict liability for directly causing harm to a moral standard based on fault. He then sets out two paradigms of liability to serve as constructs for understanding competing ideological viewpoints about the proper role of tort sanctions. He asserts that the paradigm of reciprocity, which looks only to the degree of risk imposed by the parties to a lawsuit on each (...) other, and to the existence of possible excusing conditions, provides greater protection of individual interests than the paradigm of reasonableness, which assigns liability instrumentally on the basis of a utilitarian calculus. Finally, Professor Fletcher examines stylistic differences between the two paradigms which may explain the modern preference for the paradigm of reasonableness. (shrink)

Appropriation art involves the use of pre-existing works of art with little to no transformation. Works of AA fail to satisfy established criteria for originality, such as creative labour and transformative use. As such, appropriation artists are often subject to copyright lawsuits and defend their work under the fair use doctrine of US copyright law. In legal cases regarding AA and fair use, judges lack a general principle whereby they can determine whether or not the offending party has ‘transformed’ (...) the original work. Further, it is not the case that there is some antecedent fact that could determine the outcome one way or another. I diagnose debates surrounding the transformative nature of works of AA as cases of ‘metalinguistic negotiation’ over what concepts we should attach to terms like ‘copy’, ‘transformative’, and ‘work of art’. (shrink)

On 19 July 2016, three medical organisations filed a federal lawsuit against representatives from several Vermont agencies over the Patient Choice and Control at End of Life Act. The law is similar to aid-in-dying laws in four other US states, but the lawsuit hinges on a distinctive aspect of Vermont's law pertaining to patients' rights to information. The lawsuit raises questions about whether, and under what circumstances, there is an ethical obligation to inform terminally ill patients about AID as an (...) end-of-life option. Much of the literature on clinical communication about AID addresses how physicians should respond to patient requests for assisted dying, but neglects the question of how physicians should approach patients who may not know enough about AID to request it. In this article, I examine the possibility of an affirmative duty to inform terminally ill patients about AID in light of ethical concerns about professional responsibilities to patients and the maintenance of the patient–provider relationship. I suggest that we should not take for granted that communication about AID ought to be patient-initiated, and that there may be circumstances in which physicians have good reasons to introduce the topic themselves. By identifying ethical considerations that ought to inform such discussions, I aim to set an agenda for future bioethical research that adopts a broader perspective on clinical communication about AID. (shrink)

In 2004, the Havasupai Tribe filed a lawsuit against the Arizona Board of Regents and Arizona State University researchers upon discovering their DNA samples, initially collected for genetic studies on type 2 diabetes, had been used in several other genetic studies. The lawsuit reached a settlement in April 2010 that included monetary compensation and return of DNA samples to the Havasupai but left no legal precedent for researchers. Through semistructured interviews, institutional review board chairs and human genetics researchers at US (...) research institutions revealed their perspectives on the Havasupai lawsuit. For interviewees, the suit drew attention to indigenous concerns over genetic studies and increased their awareness of indigenous views. However, interviewees perceived no direct impact from the Havasupai case on their work; if they did, it was the perceived need to safeguard themselves by obtaining broad consent or shying away from research with indigenous communities altogether, raising important questions of justice for indigenous and minority participants. If researchers and IRBs do not change their practices in light of this case, these populations will likely continue to be excluded from a majority of research studies and left with less access to resources and potential benefit from genetic research participation. (shrink)

Health research increasingly relies on organized collections of health data and biological samples. There are many types of sample and data collections that are used for health research, though these are collected for many purposes, not all of which are health-related. These collections exist under different jurisdictional and regulatory arrangements and include: 1) Population biobanks, cohort studies, and genome databases 2) Clinical and public health data 3) Direct-to-consumer genetic testing 4) Social media 5) Fitness trackers, health apps, and biometric data (...) sensors Population biobanks, cohort studies, and genome databases Clinical and public health data Direct-to-consumer genetic testing Social media Fitness trackers, health apps, and biometric data sensors Ethical, legal, and social challenges of such collections are well recognized, but there has been limited attention to the broader societal implications of the existence of these collections. Although health research conducted using these collections is broadly recognized as beneficent, secondary uses of these data and samples may be controversial. We examine both documented and hypothetical scenarios of secondary uses of health data and samples. In particular, we focus on the use of health data for purposes of: Forensic investigations Civil lawsuits Identification of victims of mass casualty events Denial of entry for border security and immigration Making health resource rationing decisions Facilitating human rights abuses in autocratic regimes Forensic investigations Civil lawsuits Identification of victims of mass casualty events Denial of entry for border security and immigration Making health resource rationing decisions Facilitating human rights abuses in autocratic regimes Current safeguards relating to the use of health data and samples include research ethics oversight and privacy laws. These safeguards have a strong focus on informed consent and anonymization, which are aimed at the protection of the individual research subject. They are not intended to address broader societal implications of health data and sample collections. As such, existing arrangements are insufficient to protect against subversion of health databases for non-sanctioned secondary uses, or to provide guidance for reasonable but controversial secondary uses. We are concerned that existing debate in the scholarly literature and beyond has not sufficiently recognized the secondary data uses we outline in this paper. Our main purpose, therefore, is to raise awareness of the potential for unforeseen and unintended consequences, in particular negative consequences, of the increased availability and development of health data collections for research, by providing a comprehensive review of documented and hypothetical non-health research uses of such data. (shrink)

Divergences and controversies are inevitable in the discussion of freedoms and rights, especially in the matter of reproduction. The Chinese first social egg freezing lawsuit raises the question: is the freedom to freeze eggs for social reasons justified because it is an instance of reproductive rights? This paper accepts social egg freezing as desirable reproductive freedom, but following Harel's approach and considering two theories of rights, the choice and interest theories of rights, we argue that social egg freezing is not (...) a reproductive right because one cannot justify a right or an instance of rights via merely describing the function of those instances that have been justified as right, that is, the choice theory lacks justifying normativity. Since reserving fertility and a suspension from reproduction do not serve reproductive ends per se, the sufficient reason for demanding social egg freezing as a right should be found in other ends rather than in right‐to‐reproduce, that is, the interest theory denies the demand as a right‐to‐reproduce. Permitting it on any grounds without guaranteeing adequate and accessible resources, especially in light of cross‐border reproductive care, raises serious questions about reproductive equality and violates the idea of reproductive rights. Therefore, any ground for social egg freezing should be weighed against whether more pressing reproductive needs, specifically those that are justified as rights, have been met. It would be social progress to shoulder these burdens for the vulnerable and then allow social egg freezing—if right‐to‐reproduce were not the only privilege of the few. (shrink)

In 1989, Helga Wanglie, 86 years old, broke her hip. This began a medical downhill course that a year later caused her health care providers to conclude that she would not benefit from continued medical treatment. It would be futile, and therefore, should not be provided. Her husband disagreed, and the conflict eventually led to a lawsuit. The Wanglie case touched off an extended debate in the medical and bioethical literature about medical futility: what it means and how useful the (...) concept is in making ethical decisions about starting or stopping treatment. (shrink)

Whether firms can be said to be moral agents and to have the capacity for moral responsibility has significant practical consequences. In most legal systems in the world, business firms are recognized as persons with the ability to own property, to maintain and defend lawsuits, and to self-organize governance structures. To recognize that these business persons can also act morally or immorally as organizations, however, would justify the imposition of other legal constraints and normative expectations on organizations. In the (...) criminal law, for example, the idea that an organized firm may itself have criminal culpability is accepted in many countries (such as the United States) but rejected in others (such as Germany). This book collects new contributions by leading business scholars in business ethics, philosophy, and related disciplines to extend our understanding of the moral responsibility of firms. (shrink)

In 2012, New York City Mayor Michael Bloomberg proposed capping the size of sugary beverages that could be sold in the city’s restaurants, sporting and entertainment facilities and food carts. After a lawsuit and multiple appeals, the proposal died in June 2014, deemed an unconstitutional overreach. In dissecting the saga of the proposed soda cap, we highlight both the political perils of certain anti-obesity efforts and, more broadly, the challenges to public health when issues of consumer choice and the threat (...) of paternalism are involved. (shrink)

pt. 1. The American Counseling Association code of ethics ; The counseling relationship ; Confidentiality and privacy ; Professional responsibility ; Relationships with other professionals ; Evaluation, assessment, and interpretation ; Supervision, training, and teaching ; Research and publication ; Distance counseling, technology, and social media ; Resolving ethical issues -- pt. 2. Decision making and ethical practice in counseling. An ethical decision-making process for counselors;- Ethical issues regarding culture and diversity ; Confidentiality ; Exceptions to confidentiality ; Counseling suicidal (...) clients ; Boundaries and multiple relationships in counseling ; Competence ; Supervision ; Managed care ; Integrating technology into counseling practice ; Termination and abandonment ; Responding to subpoenas and court orders, lawsuits, and ethics complaints -- Appendix. Resources for counselors. (shrink)

Using the infamous research studies in Tuskegee and Guatemala, the article examines the difference between victims and bystanders. The victims can include families, sexual partners, and children not just the participants. There are also the bystanders in the populations who are affected, even vaguely, decades after the initial studies took place. Differing reparations for victims and bystanders through lawsuits and historical acknowledgments has to be part of broader discussions of historical justice, and the weighing of the impact of racism (...) and imperial research endeavors. (shrink)

The concept of international strategic litigation for the defense of Venezuela is analyzed against the 2018 Guyana lawsuit before the International Court of Justice-ICJ. Evading the agreement in Article IV of the 1966 Geneva Agreement, it attempts to validate the Paris Arbitration Award of 1899, which was rejected by Guyana and Venezuela. The claim is inadmissible because the bilateral ways to resolve the territorial conflict have not been exhausted, the ICJ lacks jurisdiction and the Geneva Agreement is distorted. Scenarios are (...) analyzed for Venezuela to participate or not in the litigation, highlighting the convenience of a peaceful, practical and satisfactory settlement for the Parties. (shrink)

PHOTO ID 121339257© Designer491| Dreamstime.com ABSTRACT When physicians use their clinical knowledge and skills to advance the well-being of their patients, there may be apparent conflict between patient autonomy and physician beneficence. We are skeptical that today’s medical ethics education adequately fosters future physicians’ commitment to beneficence, which is both rationally defensible and fundamentally consistent with patient autonomy. We use an ethical dilemma that was presented to a group of third-year medical students to examine how ethics education might be causing (...) them to give undue deference to autonomy, thereby undermining their commitment to beneficence. INTRODUCTION The right of patients to choose which treatments they prefer is rooted in today’s social mores and taught as a principle of medical ethics as respect for autonomy. Yet, when physicians use their clinical knowledge and skills to advance the well-being of their patients, there may be a conflict between patient autonomy and physician beneficence. We are skeptical that today’s medical ethics education adequately fosters a commitment to beneficence, which is both rationally defensible and fundamentally consistent with patient autonomy. I. An Ethical Dilemma The impetus for this paper arose when students who were completing their third clinical year discussed a real-life ethical dilemma. A middle-aged man developed a pulmonary hemorrhage while on blood thinners for a recently placed coronary stent. The bleeding was felt to be reversible, but the patient needed immediate intubation or he would die. The cardiologist was told that the patient previously expressed to other physicians that he never wanted to be intubated. However, the cardiologist made the decision to intubate the patient anyway, and the patient eventually recovered.[1] Students were asked if they believed that the cardiologist had acted ethically. Their overwhelming response was, “No, the patient should have been allowed to die.” We looked into how students applied ethical reasoning to conclude that this outcome was ethically preferred. To explore how the third-year clinical experience might have formed the students’ judgment, we presented the same case to students who were just beginning their third year. Their responses were essentially uniform in recommending intubation. While there is likely more than one reasonable view in this case, we agree with the physician and the younger medical students that intubation was the ethically appropriate decision and will present an argument for it. But first, we explain the reasoning behind the more advanced medical students’ decision to choose patient autonomy at the expense of beneficence. II. Medical Ethics Education and the Priority of Autonomy Beauchamp and Childress’s Principles of Biomedical Ethics, first published in 1979 and now in its 8th edition, is a significant part of the formal ethics education in medical school.[2] Students learn an ethical decision-making approach based on respect for four ethical principles: autonomy, beneficence, nonmaleficence, and justice. While Beauchamp and Childress officially afford no prima facie superiority to any principle, the importance of respect for patient autonomy has increased through the editions of their book. For example, early editions of their book opposed the legalization of physician-assisted death compared to recent editions that defended it.[3] As another example, Beauchamp and Childress make paternalism harder to justify by adding an autonomy-protecting condition to the list of conditions for acceptable paternalism.[4] Authority, they contend, need not conflict with autonomy—provided the authority is autonomously chosen.[5] “The main requirement,” they write, “is to respect a particular patient’s or subject’s autonomous choices, whatever they may be.[6] In the principlism of Beauchamp and Childress, autonomy now seems to have a kind of default priority.[7] However, the bioethics discourse has strong counternarratives, noting some movement to elevate the role of beneficence and to respect the input of stakeholders, including the family and the healthcare team. Ethics education achieves particular relevance in the third clinical year when students become embedded in the care of patients and learn from what has been called the informal curriculum. They observe how attending physicians approach day-to-day ethical problems at the patient’s bedside. In this context, students observe the importance of informed consent for serious treatments or invasive procedures, a practice that highlights the principle of patient autonomy. In both the formal and informal curriculum, medical students observe how, in the words of Paul Wolpe, “patient autonomy has become the central and most powerful principle in ethical decision-making in American medicine.”[8] In short, students appear to learn a deference for patient autonomy. This curricular shift in favor of autonomy coincides with legal developments that protect patients’ rights and decision-making with respect to their healthcare choices. The priority of autonomy in medicine benefits patients by reflecting their choices and, in some cases, their fundamental liberty. III. The Practice of Medicine and the Commitment to Beneficence There are many critiques of the dominant place that autonomy has in biomedical ethics,[9] especially considering that autonomy seems to be biased toward individualistic, Western, and somewhat American culture-driven values.[10] In addition, many bioethical dilemmas are cast as a conflict between autonomy and beneficence. Our point is that medical students bring to their study of medicine a commitment to beneficence that seems to be suppressed by practical ethics education. We think this commitment is rationally defensible and should be nurtured. It is striking that young medical students have a pre-reflective commitment to beneficence at all. For, as we mentioned, it is not just medicine but Western culture generally that prioritizes autonomy in settling ethical dilemmas. In wanting to act for the good of others (rather than simply agreeing to what others want), physicians are already swimming somewhat against the cultural tide.[11] However, doing so makes sense, given the nature of medicine and the profession of healing. When prospective medical students are asked why they wish to become physicians, the usual answer is some variation on caring for the sick and preventing disease. It is unlikely that a reason to become a physician is to respect a patient’s autonomy. It would be easy to dismiss medical students’ commitment to beneficence as a mere intuition and contrary to a more reasoned and deliberative approach. Beauchamp and Childress seem to minimize the value of physician intuition, stating that justifications for certain procedures are “…supported by good reasons. They need not rest merely in intuition or feeling.”[12] Henry Richardson writes that “situational or perceptive intuition…leaves the reasons for decision unarticulated.”[13] We think this is a crude and rather thin way of understanding intuition. Some bioethicists have defended intuition as essential to the practice of medicine and not something opposed to reason.[14] In the case we describe, we believe the ethical justifications s for the patient’s intubation are fundamentally sound: the patient did not have a “do not intubate” order written in the chart, the emergency intubation had not been foreseen, so the patient did not have the opportunity to consent to or reject intubation; the patient had consented to the treatment for his cardiac disease so his consent for intubation could have been assumed;[15] and the consequences of respecting his autonomy did not justify allowing him to die.[16] While it is possible to have more than one reasonable view on this case, we think the case for beneficence is strong and certainly should not be dismissed out of hand. We do not deny that if a patient makes a clearly documented, well-informed decision to forgo intubation that this decision ought to be respected by the physician (even if the physician disagrees with the patient’s decision). But, in this situation, as in many others in the practice of medicine, the patient’s real wishes and preferences are not well-articulated in advance. There are many cases where a physician acts based on what she believes the patient, or the surrogate, would want, sometimes in situations that do not allow much time for reflection. An example might be resuscitation of a newborn at the borderline of viability. In their ethics education, beneficence would mean acting first to save a life. If the patient or surrogate makes an informed decision to the contrary, a beneficent physician respects that autonomous decision. In the case presented, the patient expressed gratitude to the cardiologist when extubated. But what if he had expressed anger at the physician for violating his autonomy? There are those who could argue that not only was intubation ethically wrong but that the cardiologist put himself in legal jeopardy by his actions (especially if there had been a written refusal applicable to the specific situation). In the example we use, we point out that the cardiologist may not have escaped a lawsuit if the patient had died without intubation. His family, when hearing the circumstances, may have sued for failure to act and dereliction of the cardiologist’s duty to save him. Beyond a potential legal challenge for either action or inaction, there is an overriding ethical question the cardiologist had to address: what course would be most satisfying to his conscience? Would he rather allow a patient to die for fear of recrimination, or act to save his life, regardless of the personal consequences? In the absence of real knowledge about the patient’s considered wishes, it is most reasonable to err on the side of promoting patient well-being. A physician’s commitment to beneficence is not necessarily a way of undermining a patient’s autonomy. In acting for the patient's good, physicians are also acting on what it is reasonable to believe a patient (or most patients, perhaps) would want, which is obviously connected to what a patient does want. Pellegrino and Thomasma argue that beneficence includes respect for a patient’s autonomy since “the best interests of the patient are intimately linked with their preferences.”[17] Instead of conceptualizing ethical dilemmas in medicine as conflicts between autonomy and beneficence, it is possible that medical schools could teach students that truly practicing beneficence is a way of valuing patient autonomy, especially when the patient’s wishes are not specific to the situation and are not clearly expressed. CONCLUSION It is important for students and practicing physicians to understand the principle of respect for patient autonomy in a pluralistic society that demands personal self-determination. However, the role of the physician as a beneficent healer should not be diminished by this respect for autonomy. Respecting a patient’s autonomy is grounded in and manifested by physician beneficence.[18] That is, seeking what is good for the patient can only be good if it respects their personhood and dignity. We propose that a commitment to beneficence, incipient in young medical students, should be developed over time with their other clinical reasoning skills. Such a commitment need not be sacrificed on the altar of patient autonomy. Beneficence needs greater relative moral weight with students as they proceed in their ethics education. - [1] S. Jauhar, “When Doctors Need to Lie,” New York Times, February 22, 2014, https://www.nytimes.com/2014/02/23/opinion/sunday/when-doctors-need-to-lie.html. [2] T. L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 8th ed. (New York, NY: Oxford University Press, 2019). [3] Louise A. Mitchell, “Major Changes in Principles of Biomedical Ethics,” The National Catholic Bioethics Quarterly 14, no. 3 (2014): 459–75, https://doi.org/10.5840/ncbq20141438. [4] Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 8th ed. (New York, NY: Oxford University Press, 2019), 238. [5] Beauchamp and Childress, 103. [6] Beauchamp and Childress, p. 108. [7] For other accounts that prioritize autonomy, see e.g. Allen E. Buchanan and Dan W. Brock, Deciding for Others: The Ethics of Surrogate Decision Making (Cambridge University Press, 1989), 38–39; R Gillon, “Ethics Needs Principles—Four Can Encompass the Rest—and Respect for Autonomy Should Be ‘First among Equals,’” Journal of Medical Ethics 29, no. 5 (October 2003): 307–12, https://doi.org/10.1136/jme.29.5.307. For examples of critiques of these accounts, see footnote 9. [8] P. R. Wolpe, “The Triumph of Autonomy in American Bioethics: A Sociological View,” in Bioethics and Society: Constructing the Ethical Enterprise, p. 43. [9] V. A. Entwistle et al., “Supporting Patient Autonomy: The Importance of Clinician-Patient Relationships,” Journal of General Internal Medicine 25, no. 7 (July 2010): 741–45; C. Foster, Choosing Life, Choosing Death: The Tyranny of Autonomy in Medical Ethics and Law, 1st ed. (Oxford ; Hart Publishing, 2009); O. O’Neill, Autonomy and Trust in Bioethics, The Gifford Lectures, University of Edinburgh 2001 (Cambridge, UK: Cambridge University Press, 2002). [10] P. Marshall and B. Koenig, “Accounting for Culture in a Globalized Bioethics,” The Journal of Law, Medicine & Ethics: A Journal of the American Society of Law, Medicine & Ethics 32, no. 2 (2004): 252–66; R. Fan, “Self-Determination vs. Family-Determination: Two Incommensurable Principles of Autonomy,” Bioethics 11, no. 3–4 (1997): 309–22. [11] Arguments stressing the importance of beneficence, as ours does here, certainly approach paternalistic arguments. We set aside the complex issue of paternalism for purposes of this paper and simply note that the principle of beneficence as such does not say anything specifically about acting against the patient’s will. In the case study that focuses this paper, we do not believe the patient’s will or wishes were clearly indicated. [12] Beauchamp and Childress, Principles of Biomedical Ethics, p. 20, see note 2 above. [13] H. S. Richardson, “Specifying, Balancing, and Interpreting Bioethical Principles,” The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine 25, no. 3 (January 1, 2000): 285–307, p. 287. [14] H. D. Braude, Intuition in Medicine a Philosophical Defense of Clinical Reasoning (Chicago ; University of Chicago Press, 2012). [15] R. Kukla, “Conscientious Autonomy: Displacing Decisions in Health Care,” The Hastings Center Report 35, no. 2 (2005): 34–44. [16] M. Schermer, The Different Faces of Autonomy: Patient Autonomy in Ethical Theory and Hospital Practice, vol. 13, Library of Ethics and Applied Philosophy (Dordrecht: Springer Netherlands, 2002). [17] E. D. Pellegrino and D. C. Thomasma, For the Patient’s Good - the Restoration of Beneficence in Health Care (New York, NY: Oxford University Press, 1988), p. 29. [18] Pellegrino and Thomasma, For the Patient’s Good. 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