Tom Beauchamp and James Childress‘s revolutionary textbook, Principles of Biomedical Ethics, shaped the field of bioethics in America and around the world. Midway through the Principle’s eight editions, however, the authors jettisoned their attempt to justify the four principles of bioethics —autonomy, beneficence, nonmaleficence, justice—in terms of ethical theory, replacing it with the idea that these principles are part of a common morality shared by all rational persons committed to morality, at all times, and in all places. Other commentators contend (...) that their theory has never been empirically confirmed and is unfalsifiable, since counterexamples can be deemed irrational, or as held by those living lives not committed to morality. The thesis of this paper is that common morality theory is the artifact of a category mistake—conflating common areas regulated by moral norms with common norms regulating moral conduct—that accords mid-twentieth century American liberal morality the status of transcultural, transtemporal, eternal moral truths. Such a conception offers bioethicists no tools for analyzing moral change—moral progress, regress, reform, evolution, devolution, or revolution—no theoretical basis for deconstructing structural classicism, racism, and sexism, or for facilitating international cooperation on ethical issues in the context of culturally based moral differences. (shrink)

After briefly sketching common-morality principlism, as presented in Principles of Biomedical Ethics, this paper responds to two recent sets of challenges to this framework. The first challenge claims that medical ethics is autonomous and unique and thus not a form of, or justified or guided by, a common morality or by any external morality or moral theory. The second challenge denies that there is a common morality and insists that futile efforts to develop common-morality approaches to bioethics limit diversity and (...) prevent needed moral change. This paper argues that these two critiques fundamentally fail because they significantly misunderstand their target and because their proposed alternatives have major deficiencies and encounter insurmountable problems. (shrink)

In her important and well-known discussion “On the Moral and Legal Status of Abortion,” Mary Anne Warren regrets that “it is not possible to produce a satisfactory defense of a woman’s right to obtain an abortion without showing that the fetus is not a human being, in the morally relevant sense.” Unlike some more cautious philosophers, Warren thinks that we can definitively demonstrate that the fetus is not a person. In this paper, Warren’s argument is critically examined with a focus (...) especially on the question of the foundation and the boundaries of the moral community. The fundamental thesis of the paper is that Warren’s approach is flawed for at least four reasons: that being a person is not as obviously central to having full moral rights as Warren assumes, that her exclusivism regarding moral status has dubious moral consequences independent of the abortion issue, that it is not clear that a fetus is not a person, even on Warren’s own criteria, and her criteria for personhood are themselves suspect. (shrink)

When humanity has either suppressed coronavirus disease 2019 or learned to come to terms with its continued existence, governments and corporations probably return to their prepandemic stances. Solutions to the world’s problems are sought from technology and business innovations, not from considerations of equality and well-being for all. This is in stark contrast with the pandemic-time situation. Many governments, at least initially, listened to the recommendations of expert advisers, most notably public health authorities, who proceeded from considerations of equality and (...) common good. I suggest that we should continue on this path when the immediate threat of the disease is over. Other crises are already ongoing—poverty, conflicts, climate change, financial bubbles, and so on—and it would be good to use expert knowledge rather than interests and ideologies in dealing with them. To assist in this, I outline the characteristics of a new kind of counsellor, impartial adviser, who is normatively motivated by a sense of copathy and who takes into account all views, nice and not-so-nice alike. I illustrate the nature and ideological orientation of copathic impartial advisers by placing them on a map of justice and examining their relationships with the main political moralities of our time. (shrink)

Is there such a thing as corona solidarity? Does voluntary mutual aid solve the problems caused by COVID-19? I argue that the answer to the first question is “yes” and to the second “no.” Not that the answer to the second question could not, in an ideal world, be “yes,” too. It is just that in this world of global capitalism and everybody looking out for themselves, the kind of communal warmth celebrated by the media either does not actually exist (...) or is too weak to rule out the uglier manifestations of group togetherness, driven partly by the pandemic. I make my point by offering two approaches to understanding what solidarity is. According to the first, it is essentially partiality: “us” against “them.” According to the second, it can be many things, including the impartial promotion of the good of others. I show that the second reading would make it possible for mutual aid to solve the problems caused by COVID-19 and other crises. This would happen at the expense of conceptual clarity, but that is a minor concern. The major concern is that the more natural manifestations of group togetherness are incited by negative feelings. This is par for the course within the narrower reading of solidarity, but it means that the potentially positive ideas of identity, care, communal values, and special relations are displayed in violent confrontation instead of a calm recognition of the threats that most of us face together. (shrink)

Tom Beauchamp and James Childress are confident that their four principles—respect for autonomy, beneficence, non-maleficence, and justice—are globally applicable to the sorts of issues that arise in biomedical ethics, in part because those principles form part of the common morality. Inevitably, however, the question arises of how the principlist ought to respond when presented with apparent counter-examples to this thesis. I examine a number of strategies the principlist might adopt in order to retain common morality theory in the face of (...) supposed counter-examples. I conclude that only a strategy that takes a non-realist view of the common morality’s principles is viable. Unfortunately, such a view is likely not to appeal to the principlist. (shrink)

This paper considers the relation between medical ethics and common morality, professional norms, and moral philosophy. It proceeds by analyzing two recent book-length critical analyses of this relationship by Bob Baker in “The Structure of Moral Revolutions—Studies of Changes in the Morality of Abortion, Death, and the Bioethics Revolution” and Rosamond Rhodes in “The Trusted Doctor—Medical Ethics and Professionalism.” It argues that despite the strengths of these critical arguments, there is nevertheless a relationship between ME, understood as the professional ethics (...) of the healthcare professions, and both CM and moral philosophy. It also argues that ME cannot and should not be understood purely as the internally developed professional norms of the medical or healthcare professions. (shrink)

Robert Baker and Rosamond Rhodes each argue against the universality “common morality,” the approach to ethics that comprises four fundamental principles and their application in various settings. Baker contends that common morality cannot account for cultural diversity in the world and claims that a human rights approach is superior in the context of global health. Rhodes maintains that bioethics is not reducible to common morality because medical professionals have special privileges and responsibilities that people lack in everyday life. Baker fails (...) to demonstrate how the human rights approach to global ethics is more sensitive to culture than the use of bioethics principles that comprise common morality. Rhodes has a narrow interpretation of “common morality,” which when understood more broadly, accounts for the special privileges and obligation of medical professionals. (shrink)

Engagement in health research is increasingly practised worldwide. Yet many questions remain under debate in the ethics field about its contribution to health research and these debates have largely not been informed by those who have been engaged in health research. This paper addresses the following key questions: what should the ethical goals of engagement in health research be and how should it be performed? Qualitative data were generated by interviewing 22 people with lived experience, members of the public, and (...) engagement managers about power sharing in health research. Thematic analysis of study data identified the following five themes: the value of engagement in research, ideal engagement, tokenistic engagement, terms to describe those engaged, and engagement roles in research. The paper presents that data and then considers what insights it offers for what engagement should look like—its ethical goals and approach—according to those being engaged. (shrink)

In responding to my critics, James Childress, Tom Beauchamp, Soren Holm, and Ruth Macklin, I reprise my arguments for medical ethics being an uncommon morality. I also elaborate on points that required further clarification. I explain the role of trust and trustworthiness in the creation of a profession. I also describe my views on the relationship of the medical profession to the society in which medicine is practiced. Finally, I defend my claim that medical ethics “is constructed by medical professionals (...) for medical professionals” by describing the profession’s unique vantage point for regulating and policing the profession’s uncommon powers and privileges. (shrink)

This paper argues that we ought to rethink the harm-reduction prioritization strategy that has shaped early responses to acute resource scarcity during the COVID-19 pandemic. Although some authors have claimed that “[t]here are no egalitarians in a pandemic,” it is noted here that many observers and commentators have been deeply concerned about how prioritization policies that proceed on the basis of survival probability may unjustly distribute the burden of mortality and morbidity, even while reducing overall deaths. The paper further argues (...) that there is a general case in favor of an egalitarian approach to medical rationing that has been missed in the ethical commentary so far; egalitarian approaches to resource rationing minimize wrongful harm. This claim is defended against some objections and the paper concludes by explaining why we should consider the possibility that avoiding wrongful harm is more important than avoiding harm simpliciter. (shrink)

The removal of controversial names and monuments from the public sphere in the United States has gained traction in the context of efforts to achieve social justice for historically mistreated and marginalized communities. Such debates are increasingly raising issues in the healthcare setting as hospitals and medical schools grapple with the legacies of figures whose scientific contributions are clouded with ethical transgressions. Present efforts to address these challenges have largely occurred at the institutional level. The results have been guidelines that (...) are complex, highly inconsistent across institutions, and largely downplay the symbolic importance of such historical redress. This paper proposes a simpler three-part test for name and monument removal in the medical and hospital settings that places greater weight on the symbolic importance of the renaming process itself instead of only considering the outcomes. (shrink)

Two of the most poignant decisions in pediatrics concern disagreements between physicians and families over imperiled newborns. When can the family demand more life-sustaining treatment than physicians want to provide? When can it properly ask for less? The author looks at these questions from the point of view of decision theory, and first argues that insofar as the family acts in the child’s best interest, its choices cannot be constrained, and that the maximax and minimax strategies are equally in the (...) child’s best interest. He then proposes a guideline according to which the family can demand LST if it is physiologically possible to preserve a life the child can be expected to welcome, and refuse such treatment if it causes suffering that is “more than can be borne” even if an uncompromised life is expected to emerge. (shrink)

Euthanasia and physician-assisted suicide are common practice in the Netherlands. In response to increasing requests from patients to end their lives, physicians are finding themselves placed in particularly precarious situations because of advance directives written by patients suffering from severe dementia. In April 2020, the Supreme Court of the Netherlands issued two judgments in the so-called Dormicum case: a case involving the deliberate termination of the life of a 74-year-old woman suffering from advanced dementia by a geriatrician in a nursing (...) home in The Hague. The judgment of the lower criminal court was upheld, but the sanction imposed by the appellate disciplinary court was quashed. In this paper, the author reviews the two Supreme Court rulings, argues that both are fundamentally flawed and raises questions as to what they mean for Dutch criminal law, physicians, and patients going forward. (shrink)

How should we respond to patients who do not wish to take on the responsibility and burdens of making decisions about their own care? In this paper, we argue that existing models of decision-making in modern healthcare are ill-equipped to cope with such patients and should be supplemented by an “appointed fiduciary” model where decision-making authority is formally transferred to a medical professional. Healthcare decisions are often complex and for patients can come at time of vulnerability. While this does not (...) undermine their capacity, it can be excessively burdensome. Most existing models of decision-making mandate that patients with capacity must retain ultimate responsibility for decisions. An appointed fiduciary model provides a formalized mechanism through which those few patients who wish to defer responsibility can hand over decision-making authority. By providing a formal structure for deferring to an appointed fiduciary, the confusions and risks of the informal transfers that can occur in practice are avoided. Finally, we note how appropriate governance and law can provide safeguards against risks to the welfare of patients and medical professionals. -/- . (shrink)

Important advances in biomedical and behavioral research ethics have occurred over the past few decades, many of them centered on identifying and eliminating significant harms to human subjects of research. Comprehensive attention has not been paid to the totality of harms experienced by animal subjects, although scientific and moral progress require explicit appraisal of these harms. Science is a public good and the prioritizing within, conduct of, generation of, and application of research must soundly address questions about which research is (...) morally defensible and valuable enough to support through funding, publication, tenure, and promotion. Likewise, educational pathways of re-imagined science are critical. (shrink)

The application of machine-learning technologies to medical practice promises to enhance the capabilities of healthcare professionals in the assessment, diagnosis, and treatment, of medical conditions. However, there is growing concern that algorithmic bias may perpetuate or exacerbate existing health inequalities. Hence, it matters that we make precise the different respects in which algorithmic bias can arise in medicine, and also make clear the normative relevance of these different kinds of algorithmic bias for broader questions about justice and fairness in healthcare. (...) In this paper, we provide the building blocks for an account of algorithmic bias and its normative relevance in medicine. (shrink)

The coronavirus crisis is causing considerable disruption and anguish. However, the COVID-19 pandemic and consequent explosion of telehealth services also provide an unparalleled opportunity to consider ethical, legal, and social issues beyond immediate needs. Ethicists, informaticians, and others can learn from experience, and evaluate information technology practices and evidence on which to base policy and standards, identify significant values and issues, and revise ethical guidelines. This paper builds on professional organizations’ guidelines and ELSI scholarship to develop emerging concerns illuminated by (...) current experience. Four ethical themes characterized previous literature: quality of care and the doctor–patient relationship, access, consent, and privacy. More attention is needed to these and to expanding the scope of ethical analysis to include health information technologies. An applied ethics approach to ELSI would addresses context-specific issues and the relationships between people and technologies, and facilitate effective and ethical institutionalization of telehealth and other health information technologies. (shrink)

This paper argues that uterine transplants are a potentially dangerous distraction from the development of alternative methods of providing reproductive options for women with absolute uterine factor infertility. We consider two alternatives in particular: the bioengineering of wombs using stem cells and ectogenesis. Whether biologically or mechanically engineered, these womb replacements could provide a way for women to have children, including genetically related offspring for those who would value this possibility. Most importantly, this alternative would avoid the challenge of sourcing (...) wombs for transplant, a practice that we argue would likely be exploitative and unethical. Continued research into bioengineering and ectogenesis will therefore remain morally important despite the recent development of uterine transplantation, even if the procedure reaches routine clinical application. (shrink)

Teaching healthcare ethics at the doctoral level presents a particular challenge. Ethics is often taught to medical students, but rarely is medicine taught to graduate students in health care ethics. In this paper, Medicine for Ethicists [MfE] — a course taught both didactically and experientially — is described. Eight former MfE students were independently interviewed in a semi-structured, open-ended format regarding their experience in the experiential component of the course. Themes included concrete elements about the course, elements related to the (...) broader PhD student learning experience, and themes related to the students’ past and future career experiences. Findings are related to the educational philosophy of John Dewey and David Kolb’s experiential learning theory. Broader implications of this work are explored. (shrink)

The purpose of this article is to show that animal rights are not necessarily at odds with the use of animals for research. If animals hold basic moral rights similar to those of humans, then we should consequently extend the ethical requirements guiding research with humans to research with animals. The article spells out how this can be done in practice by applying the seven requirements for ethical research with humans proposed by Ezekiel Emanuel, David Wendler and Christine Grady to (...) animal research. These requirements are i) social value, ii) scientific validity, iii) independent review, iv) fair subject selection, v) favorable risk-benefit ratio, vi) informed consent, and vii) respect for research subjects. In practice, this means that we must reform the practice of animal research to make it more similar to research with humans, rather than completely abolish the former. Indeed, if we banned animal research altogether, then we would also deprive animals of its potential benefits – which would be ethically problematic. (shrink)

The amount of data available to healthcare practitioners is growing, and the rapid increase in available patient data is becoming a problem for healthcare practitioners, as they are often unable to fully survey and process the data relevant for the treatment or care of a patient. Consequently, there are currently several efforts to develop systems that can aid healthcare practitioners with reading and processing patient data and, in this way, provide them with a better foundation for decision-making about the treatment (...) and care of patients. There are also efforts to develop algorithms that provide suggestions for such decisions. However, the development of these systems and algorithms raises several concerns related to the privacy of patients, the patient–practitioner relationship, and the autonomy of healthcare practitioners. The aim of this article is to provide a foundation for understanding the ethical challenges related to the development of a specific form of data-processing systems, namely clinical algorithms. (shrink)

This article addresses ethical concerns with the use of electronic health records (EHRs) by physicians in clinical practice. It presents arguments for two claims. First, requiring physicians to maintain patient EHRs for medically unnecessary tasks is likely contributing to increased burnout, decreased quality of care, and potential risks to patient safety. Second, medical institutions have ethical reasons to employ medical scribes to maintain patient EHRs. Finally, this article reviews central objections to employing medical scribes and provides responses to each.