At the center of medical morality is the healing relationship. It is defined by three phenomena: the fact of illness, the act of profession, and the act of medicine. The first puts the patient in a vulnerable and dependent position; it results in an unequal relationship. The second implies a promise to help. The third involves those actions that will lead to a medically competent healing decision. But it must also be good for the patient in the fullest possible sense. (...) The physician cannot fully heal without giving the patient an understanding of alternatives such that he or she can freely arrive—together with the physician—at a decision in keeping with his or her personal morality and values. In today's pluralistic society, universal agreement on moral issues between physicians and patients is no longer possible. Nevertheless, a reconstruction of professional ethics based on a new appreciation of what makes for a true healing relationship between patient and physician is both possible and necessary. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:President’s Council on BioethicsEdmund D. Pellegrino (bio) and F. Daniel Davis (bio)Approximately two weeks before what was to have been its final meeting, the White House dissolved the President’s Council on Bioethics by terminating the appointments of its 18 members. The letters of dismissal, dated 10 June 2009, informed the members that their service on the Council would end with the close of business the next day.The Council’s (...) term was set to expire on 30 September 2009. After President Obama’s election in November and during the transition, we were advised to proceed on the assumption that the Council would be permitted to cease on that date. Reasons for the abrupt move to disband the Council are unknown. We have accepted the fact that we Council members served at the pleasure of the President and that he simply exercised his rightful prerogative. No explanation is therefore required.Some observers have speculated that the action was retaliatory. They related to the fact that several members of the Council disagreed with the President’s stem cell policy in a signed statement published in the Hastings Center’s Bioethics Forum. Others have speculated that the move was pre-emptive. At its final meeting, scheduled for 25–26 June, the Council was set to sign-off on two of its final publications. One was a comprehensive report on the ethics of organ transplantation, and the other a white paper entitled Health Care and the Common Good. The aim was immediately to release the latter as a contribution to the intensifying debate about health care reform. Health Care and the Common Good could well have aided rather than impeded the President’s drive to better control health care costs and achieve universal coverage. The Council report attempted to ground both goals in the ethical framework of, as the title indicates, the common good of all Americans.In his letter terminating the members’ appointments, Assistant to the President for Presidential Personnel Don Gips said that the President “recognizes the values of having a commission of experts in bioethical issues to provide objective and non-ideological bioethics advice to his administration.” Gips went on to say that the President is “currently rethinking the purposes and goals of such a bioethics commission, and is carefully considering a revitalized mission and mandate.” And, [End Page 309] responding to media enquiries, White House press officer Reid Cherlin explained that the President’s Council was terminated because it was a “philosophically leaning advisory group” and, according to a New York Times account by Nicholas Wade, “because it favored discussion over developing a shared consensus.” As for the ultimate outcome of the President’s “rethinking,” Cherlin indicated that President Obama will appoint a new commission with the mandate of offering “practical policy options” in bioethics.In the light of our experiences with the Council, we leave it with hopes that certain questions of national importance will be addressed. In light of the nature of federal advisory commissions, what is or are the proper roles of a national bioethics commission? If the aim is to provide advice and counsel to the President or, perhaps to the U. S. Congress, is that advice best rendered as a group consensus or as an in-depth exploration of the inevitably conflicting ethical perspectives on a given issue? How should such a commission be constituted—with what sorts of individuals? And what is the nature of the expertise that they individually and collectively bring to the commission’s functions? If the commission is to promote public debate and discussion, how exactly should it go about that task? And how is the efficacy of a commission to be assessed? Such questions inevitably lead us deep into contested territory, as the experience of this Council has shown: into the intersections of politics, religion, and science and into the relations between practice and theory—between policy and what some seem to deride as “philosophy.” Indeed, policy without an underlying philosophy is an edifice without a foundation; philosophy without policy is a foundation without an edifice.At the last meeting of the Council in March 2009, we launched a discussion of these questions with the... (shrink)

This response to Kevin WildesÕs article in the previous issue of the Kennedy Institute of Ethics Journal addresses several major points of disagreement between Pellegrino and Wildes regarding the nature and scope of a philosophy of medicine, in particular how it is derived and by what method of philosophical enquiry it is best pursued.

A decade ago, we reviewed the field of clinical ethics; assessed its progress in research, education, and ethics committees and consultation; and made predictions about the future of the field. In this article, we revisit clinical ethics to examine our earlier observations, highlight key developments, and discuss remaining challenges for clinical ethics, including the need to develop a global perspective on clinical ethics problems.

In recent years, virtue theories have enjoyed a renaissance of interest among general and medical ethicists. This book offers a virtue-based ethic for medicine, the health professions, and health care. Beginning with a historical account of the concept of virtue, the authors construct a theory of the place of the virtues in medical practice. Their theory is grounded in the nature and ends of medicine as a special kind of human activity. The concepts of virtue, the virtues, and the virtuous (...) physician are examined along with the place of the virtues of trust, compassion, prudence, justice, courage, temperance, and effacement of self-interest in medicine. The authors discuss the relationship between and among principles, rules, virtues, and the philosophy of medicine. They also address the difference virtue-based ethics makes in confronting such practical problems as care of the poor, research with human subjects, and the conduct of the healing relationship. This book woith the author's previous volumes, A Philosophical Basis of Medical Practice and For the Patient's Good, are part of their continuing project of developing a coherent moral philosophy of medicine. (shrink)

In this companion volume to their 1981 work, A Philosophical Basis of Medical Practice, Pellegrino and Thomasma examine the principle of beneficence and its role in the practice of medicine. Their analysis, which is grounded in a thorough-going philosophy of medicine, addresses a wide array of practical and ethical concerns that are a part of health care decision-making today. Among these issues are the withdrawing and withholding of nutrition and hydration, competency assessment, the requirements for valid surrogate decision-making, quality-of-life (...) determinations, the allocation of scarce health care resources, medical gatekeeping, and for-profit medicine. The authors argue for the restoration of beneficence to its place as the fundamental principle of medical ethics. They maintain that to be guided by beneficence a physician must perform a right and good healing action which is consonant with the individual patient 's values. In order to act in the patient 's best interests, or the patient 's good, the physician and patient must discern what that good is. This knowledge is gained only through a process of dialogue between patient and/or family and physician which respects and honors the patient 's autonomous self-understanding and choice in the matter of treatment options. This emphasis on a dialogical discernment of the patient 's good rejects the assumption long held in medicine that what is considered to be the medical good is necessarily the good for this patient. In viewing autonomy as a necessary condition of beneficence, the authors move beyond a trend in the medical ethics literature which identifies beneficence with paternalism. In their analysis of beneficence, the authors reject the current emphasis on rights- and duty-based ethical systems in favor of a virtue-based theory which is grounded in the physician- patient relationship. This book's provocative contributions to medical ethics will be of great interest not only to physicians and other health professionals, but also to ethicists, students, patients, families, and all others concerned with the relationship of professional to patient and patient to professional in health care today. (shrink)

Book reviewed in this article: For the Patient's Good: The Restoration of Beneficence in Health Care. By Edmund D. Pellegrino and David C. Thomasma.

The moral authority for professional ethics in medicine customarily rests in some source external to medicine, i.e., a pre-existing philosophical system of ethics or some form of social construction, like consensus or dialogue. Rather, internal morality is grounded in the phenomena of medicine, i.e., in the nature of the clinical encounter between physician and patient. From this, a philosophy of medicine is derived which gives moral force to the duties, virtues and obligations of physicians qua physicians. Similarly, an ethic specific (...) to the other healing professions, law, teaching or ministry, can be derived from the specific ends to telos of each of these professions, which like medicine, are focused on a special type of human relationship. (shrink)

Virtue is the most perdurable concept in the history of ethics, which is understandable given the ineradicability of the moral agent in the events of the moral life. Historically, virtue enjoyed normative force as long as the philosophical anthropology and the metaphysics of the good that grounded virtue were viable. That grounding has eroded in both general and medical ethics. If virtue is to be restored to a normative status, its philosophical underpinnings must be reconstructed. Such reconstruction seems unlikely in (...) general ethics, where the possibility of agreement on the good for humans is remote. However, it is a realistic possibility in the professional ethics of the health professions where agreement on the telos of the healing relationship is more likely to arise. Nevertheless, virtue-based ethics must be related conceptually and normatively to other ethical theories in a comprehensive moral philosophy of the health professions. (shrink)

What the philosophy of medicine is -- Philosophy of medicine: should it be teleologically or socially construed? -- The internal morality of clinical medicine: a paradigm for the ethics of the helping and healing professions -- Humanistic basis of professional ethics -- The commodification of medical and health care: the moral consequences of a paradigm shift from a professional to a market ethic -- Medicine today: its identity, its role, and the role of physicians -- From medical ethics to a (...) moral philosophy of the professions -- Moral choice, the good of the patient, and the patient's good -- The four principles and the doctor-patient relationship: the need for a better linkage -- Patient and physician autonomy: conflicting rights and obligations in the physician-patient relationship -- Character, virtue, and self-interest in the ethics of the professions -- Toward a virtue-based normative ethics for the health professions -- The physician's conscience, conscience clauses, and religious belief: a Catholic perspective -- The most humane of the sciences, the most scientific of the humanities -- The humanities in medical education: entering the post-evangelical era -- Agape and ethics: some reflections on medical morals from a catholic christian perspective -- Bioethics at century's turn: can normative ethics be retrieved? -- Hippocratic tradition -- Toward an expanded medical ethics: the Hippocratic ethic revisited -- Medical ethics: entering the post-Hippocratic era. (shrink)

At the center of medical morality is the healing relationship. It is defined by three phenomena: the fact of illness, the act of profession, and the act of medicine. The first puts the patient in a vulnerable and dependent position; it results in an unequal relationship. The second implies a promise to help. The third involves those actions that will lead to a medically competent healing decision. But it must also be good for the patient in the fullest possible sense. (...) The physician cannot fully heal without giving the patient an understanding of alternatives such that he or she can freely arrive—together with the physician—at a decision in keeping with his or her personal morality and values. In today's pluralistic society, universal agreement on moral issues between physicians and patients is no longer possible. Nevertheless, a reconstruction of professional ethics based on a new appreciation of what makes for a true healing relationship between patient and physician is both possible and necessary. (shrink)

A decade ago, we reviewed the field of clinical ethics; assessed its progress in research, education, and ethics committees and consultation; and made predictions about the future of the field. In this article, we revisit clinical ethics to examine our earlier observations, highlight key developments, and discuss remaining challenges for clinical ethics, including the need to develop a global perspective on clinical ethics problems.

Fifty years ago, 23 Nazi physicians were defendants before a military tribunal in Nuremberg, charged with crimes against humanity. During that trial, the world learned of their personal roles in human experimentation with political and military prisoners, mass eugenic sterilizations, state-ordered euthanasia of the and the program of genocide we now know as the Holocaust. These physicians, and their colleagues who did not stand trial, were universally condemned in the free world as ethical pariahs. The term became the paradigm for (...) total defection from the most rudimentary elements of medical morality. The caduceus literally became the instrument of the swastika. (shrink)

Richard Lamm is an eloquent and insistent advocate for healthcare reform. In his paper, he argues that if reform is to be effective, a radical metamorphosis in the values underlying our present system must take place. “New realities” have made the “old values” unsustainable. Unless they are replaced by “new values,” we face a future of disastrous overspending, gross inequities in accessibility, poorer health for many, and more expensive dying.

In 1991, Diane Wood Middlebrook, a professor of English at Stanford University, published a biography of the poet Anne Sexton in which, among other things, she used as source material some 300 tapes of Sexton's psychotherapeutic sessions with her psychiatrist, Dr. Martin Orne. After some years of reluctance and with the concurrence of Sexton's daughter and literary executor, Linda Gray Sexton, Orne released the tapes to Professor Middlebrook. Middlebrook's picture of Sexton drew heavily on the tapes, supplemented by scrapbooks, letters, (...) photos, clippings, unpublished poems, and hospital records. (shrink)

Christian health care professionals in our secular and pluralistic society often face uncertainty about the place religious faith holds in today's medical practice. Through an examination of a virtue-based ethics, this book proposes a theological view of medical ethics that helps the Christian physician reconcile faith, reason, and professional duty. Edmund D. Pellegrino and David C. Thomasma trace the history of virtue in moral thought, and they examine current debate about a virtue ethic's place in contemporary bioethics. Their (...) proposal balances theological ethics, based on the virtues of faith, hope, and charity, with contemporary medical ethics, based on the principles of beneficence, justice, and autonomy. The result is a theory of clinical ethics that centers on the virtue of charity and is manifest in practical moral decisions. Using Christian bioethical principles, the authors address today's divisive issues in medicine. For health care providers and all those involved in the fields of ethics and religion, this volume shows how faith and reason can combine to create the best possible healing relationship between health care professional and patient. (shrink)

Commodification of health care is a central tenet of managed care as it functions in the United States. As a result, price, cost, quality, availability, and distribution of health care are increasingly left to the workings of the competitive marketplace. This essay examines the conceptual, ethical, and practical implications of commodification, particularly as it affects the healing relationship between health professionals and their patients. It concludes that health care is not a commodity, that treating it as such is deleterious to (...) the ethics of patient care, and that health is a human good that a good society has an obligation to protect from the market ethos. (shrink)

This collection of essays, commissioned by the President’s Council on Bioethics, explores a fundamental concept crucial to today’s discourse in law and ethics in general and in bioethics in particular. Since its formation in 2001, the council has frequently used the term “human dignity” in its discussions and reports. In this volume scholars from the fields of philosophy, medicine and medical ethics, law, political science, and public policy address the issue of what the concept of “human dignity” entails and its (...) proper role in bioethical controversies. __Human Dignity and Bioethics_ _is an attempt to clarify a controversial concept, one that is a critical component in the decisions of policymakers. (shrink)

The article offers an approach to inquiry about, the foundation of medical ethics by addressing three areas of conceptual presupposition basic to medical ethical theory. First, medical ethics must presuppose a view about the nature of medicine. it is argued that the view required by a cogent medical morality entails that medicine be seen both as a healing relationship and as a practical art. Three ways in which medicine inherently involves values and valuation are presented as important, i.e., in being (...) aimed at the good of health, in being a cognitive art evaluating towards that good, and as a manifestation of a virtuous disposition concerning that good. Finally, a value ontology drawn from these considerations is seen as necessarily underlying medical ethics. A set of three such basic values are promoted as crucial: the value of health; the value of the individual patient; and the value of altruism that mediates the class of potential patients. (shrink)

For ten years, 1971–1981, the Institute onHuman Values in Medicine (IHVM) played a keyrole in the development of Bioethics as afield. We have written this history andanalysis to bring to new generations ofBioethicists information about the developmentof their field within both the humanitiesdisciplines and the health professions. Thepioneers in medical humanities and ethics cametogether with medical professionals in thedecade of the 1960s. By the 1980s Bioethics wasa fully recognized discipline. We show the rolethat IHVM programs played in defining thefield, training (...) faculty and helping schools todevelop programs. We review the beginnings ofthe IHVM in the crucible of social andtechnological change that led to theestablishment of the IHVM's parentorganization, the Society for Health and HumanValues. We then turn to the IHVM programsthrough which Faculty members receivedfellowships to explore new crossovers betweenthe humanities and the health professions. Wehave not only described the Fellows Program asit existed in 1973–1980, but have completed asurvey of the fellows a quarter of a centuryafter they held their fellowships. We describeother IHVM programs designed to facilitate theinitiation and development of new humanitiesprograms, to explore conceptual issues betweenmedicine and five humanities fields, to conductissue driven or educational method conferencesand to advance humanities programs intograduate education through the Directors ofMedical Education. (shrink)

Mehlman and Massey examine possible legal responses to the issues that confront physicians faced with treating patients who have insufficient financial resources. This commentary explores the same issues from the perspective of ethics, including a comparison of the way law and ethics interpret the physician-patient relationship, the ethical obligations of physicians that are inherent in that relationship, and the propriety of Mehlman and Massey's legal and ethical proposals to ameliorate physicians' conflicting obligations in providing or withholding care on grounds of (...) conservation of society's resources. (shrink)

What it means to be a medical professional has been defined by medical ethicists throughout history and remains a contemporary concern addressed by this paper. A medical professional is generally considered to be one who makes a public promise to fulfill the ethical obligations expressed in the Hippocratic Code. This presentation summarizes the history of medical professionalism and refocuses attention on the interpersonal relationship of doctor and patient. This keynote address was delivered at the Founders of Bioethics International Congress (June, (...) 2010). (shrink)

SummaryThe congruence between medicine and philosophy which we find in the Protagoras and the Treatise on Ancient Medicine as well as the tensions symbolized in the dialectic between Eryximachus and Diotima will always be with us. The congruence and the divergence of these ancient disciplines are both important to human well-being. By opposing one another, medicine and philosophy can each balance the other's pretension to universality. By converging, they illumine some of the most important questions of human existence. This essay (...) has examined ways in which medicine and philosophy can converge in our times as philosophy and medicine, philosophy in medicine, and philosophy of medicine. The present moment in our intellectual history is particularly propitious for the nurture of the engagement of medicine and philosophy. The most fruitful form of that interaction may be in the philosophy of medicine, which is a definable discipline with a set of issues specific to it. If the obvious intellectual dangers can be avoided, those who practice medicine, those who think about it, and those who are served by it can gain deeper insight into the nature and the purpose of medicine as well as the nature of the profession and of man himself. Perhaps—positioned as it is, at the intersection of the sciences, the humanities, and technology—medicine can become “… a medium and the focus in which the problems of wisdom and science meet” (Buchanan 1938, p. 194). (shrink)

Exploring the moral foundations of the healing relationship, Edmund D. Pellegrino and David C. Thomasma offer the health care professional a highly readable Christian philosophy of medicine. This book examines the influence religious beliefs have on the kind of person the health professional should be, on the health care policies a society should adopt, and on what constitutes healing in its fullest sense. Helping and Healing looks at the ways a religious perspective shapes the healing relationship and the (...) ethics of that relationship. Pellegrino and Thomasma seek to clarify the role of religious belief in health care by providing a moral basis for such commitment as well as a balancing role for reason. This book establishes a common ground for believers and skeptics alike in their dedication to relieve suffering by showing that helping and healing require an involvement in the religious values of patients. It clearly argues that religion provides crucial insights into medical practice and morality that cannot be ignored, even in our morally heterogeneous society. Central to the authors' message is the concept of patients' vulnerabilities and the need to help them recover not only from the disease but also from an existential assault on their personhood. They then show how this understanding can move caregivers to view their professions as vocations and thereby change the nature of health care from a business to a community of healing. Physicians, nurses, administrators, clergy, theologians, and other health professionals and church leaders will find this volume helpful for their own reflections on the role of religion in the health care ministry and for making a religious commitment integral to their professional lives. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Origins and Evolution of Bioethics: Some Personal ReflectionsEdmund D. Pellegrino (bio)AbstractBioethics was officially baptized in 1972, but its birth took place a decade or so before that date. Since its birth, what is known today as bioethics has undergone a complex conceptual metamorphosis. This essay loosely divides that metamorphosis into three stages: an educational, an ethical, and a global stage. In the educational era, bioethics focused on (...) a perceived “dehumanization” of medicine by the rising power of science and technology. Remedies were sought by introducing humanities, ethics, and human “values” into the medical curriculum. Ethics was one among the humanistic disciplines, but not the dominant one. In the second era, ethics assumed a dominant role as ever more complex dilemmas emerged from the rapid pace of biological research. As such dilemmas were applied to medical practice, the need for a more rigorous and more formal analysis of their moral status was clear. Philosophically-trained ethicists had an obvious role. They began to teach, write, and profoundly influence medical education and practice. In the third—and present—period, the breadth of problems has become so broad that ethicists must, themselves, draw on disciplines well beyond their expertise—e.g., law, religion, anthropology, economics, political science, psychology, and the like. The era of bioethics as a global enterprise is upon us. The original hope for humanizing medicine has not been overtly successful; however, much has been accomplished of value to patients, the profession, and society. Medical morality has been transformed into a formal, systematic study of a whole range of issues of the greatest significance to humanity. Now the major challenge is one of identity, or inter-relationships and connections between the theoretical and the practical. Bioethics has outgrown its beginnings.I have been invited to give a “personal recollection” of the early development of bioethics. Such invitations are notoriously hard to resist, but also problematic when they are the recollections of a participant [End Page 73] in the events to be described. We need only be reminded of the vagaries common to the plethora of memoirs on the book stands today. Few have escaped the perils of selective memory, self-promotion, or the settling of old scores. Yet their perils notwithstanding, memoirs may serve some useful purpose. They are the raw material—verbal kitchen middens so to speak—out of which historians can later sift fact from fancy. They enable “tribal elders” to give witness to the past from which the present can fashion some sense of continuity.I will organize my reflections around three very arbitrary time periods that represent my own way of thinking about the evolution of bioethics: (1) an era of “proto-bioethics” (1960–1972), (2) an era of philosophical bioethics (1972–1985), and (3) an era of global bioethics (1985-present). Each era, of course, overlaps with the others, and the dominant strand of each runs through the others as well.In the proto-bioethics period, the language of human values predominated; in the era of bioethics philosophically construed, it was the language of philosophical ethics; and in the era of bioethics globally construed, the social and behavioral sciences have gained greater prominence. In each period, interest in the traditional humanities other than philosophy waxed and waned. In the earlier years, religion and theology predominated. Beginning in the 1970s, philosophy took a dominant role. In the last two decades, other disciplines, like law, literature, and the social sciences, have exerted more and more influence (McNeur 1963; Pellegrino 1997; Barker 1987).I make no pretense here of writing any part of the formal “history” of bioethics. Works of this nature are beginning to appear (Rothman 1991; Jonsen 1998 ; Dell’Oro and Viafora 1996). Thomas McElhinney and I are preparing our own account of the work and influence of the Institute on Human Values in Medicine, one of the influential programs of the Society for Health and Human Values (Pellegrino and McElhinney, n.d.). Space limitations as well as prudence preclude any attempt to do justice to all the events, institutions, and people who have made the field of bioethics what it is today. I apologize for these omissions, for any unintentional lapses of... (shrink)

“Hence it is necessary for a Prince wishing to hold his own to know how to do wrong and to make use of it according to necessity.”—Machiavelli“Every state is a community of some kind and every community is established with a view to some good…”—Aristotle.

: Managed care per se is a morally neutral concept; however, as practiced today, it raises serious ethical issues at the clinical, managerial, and social levels. This essay focuses on the ethical issues that arise at the bedside, looking first at the ethical conflicts faced by the physician who is charged with responsibility for care of the patient and then turning to the way in which managed care exacts costs that are measured not in dollars but in compromises in the (...) caring dimensions of the patient-physician relationship. (shrink)

The ethics of clinical research may be viewed from three different perspectives: the process of acquiring new knowledge, the moral use of the knowledge acquired, and the ethics of the investigator seeking this knowledge.